EDITORIALS ANZJSurg.com
Trauma verification: for the trauma centre or for the trauma system? This month’s issue of the ANZ Journal of Surgery presents a paper about the potential hurdles in meeting the resource requirements of Trauma Verification Program.1 It is timely to update and reassess the needs when the actual programme is also going through changes. Trauma centres are ‘designated’ by state or federal government but this does not necessarily mean that these institutions meet criteria of optimal care delivery of injured patients according to the standards of trauma surgical professional body of the country. Beyond designation, trauma centres have to be also ‘verified’ to ensure the optimal medical care provision. The Trauma Verification Program is one of the Royal Australasian College of Surgeons Trauma Committee’s most important activities, which has enormous, almost immediately visible impact on trauma care delivery. The Australasian Program was developed based on the Trauma Verification Program of the American College of Surgeons Committee on Trauma. The fundamental difference between the two programmes is that the Australasian verification is performed by a multidisciplinary team (general surgery, orthopaedic surgery, intensive care, emergency medicine and trauma nursing) while the American programme is run by surgical peer-review. The principle of peer review-based benchmarking of the trauma centres is a powerful tool to show hospital/health service administration the potential strengths and weaknesses of individual institutions’ trauma care delivery. Our trauma verification programme started under the chair of Dr Jim McGrath in 2000 with a Royal Australasian College of Surgeons grant for 24 months of pilot of six consultative visits. Forty-four site visits have been undertaken to 32 different hospitals during the last 14 years. Usually, a hospital requests a consultative visit first, which identifies needs for improvements, and is followed by a formal verification visit within a set time frame resulting in an outcome of yes or no. To date, in Australia there are only six hospitals (Liverpool, John Hunter, St George, Royal Perth, Royal Melbourne and Royal Brisbane and Women’s in chronological order) that are verified as level-1 trauma centre. Personally, I consider this is a very slow uptake. The Australasian Trauma Verification Program is currently being reviewed and updated to address the changes that occurred during the last 14 years. There are few key points need to be considered. I believe the first and most important is to shift the aim of the Programme from verifying individual trauma centres to verifying trauma systems. Level-1 (24/7 ability to look after any injured patients with education, research and quality assurance programme) trauma centres can perform well on the verification process individually while the entire trauma system (the network of lower level trauma hospitals, pre-hospital care, inter-hospital transfer arrangements, outreach education programme) could have major insufficiencies. Also, the need and the role of individual Level-1 trauma © 2014 Royal Australasian College of Surgeons
centres will be more obvious with this approach. Some of our states are struggling with establishing their trauma system. Victoria is the usual positive example with its highly centralized system and documented improvements in outcomes, but even there only the Level-1 trauma centres had formal or consultative verification visits. Capital cities like Perth, Adelaide and Sydney have either unclear or suboptimal pre-hospital transport arrangements or far too many designated Level-1 trauma centres per population. The integration of the Australian Capital Territory into the New South Wales trauma system needs to be formalized and based on medical rather than political priorities. The independent interstate and international peer review can help to facilitate these fundamental changes. The good examples where a larger geographic area or trauma system was reviewed so far were Northern Territory (2004), Queensland (2009) and Midland Region in New Zealand (2013). The second important change that has to happen is the adjustment of the trauma centre definitions to the Australasian specifics rather than simply adopt the North American criteria. The best example to this is that the Level-2 trauma centre (24/7 ability to treat definitively any trauma patients but no formal academic affiliation and teaching/ research) is not an existing model in our countries. Any designated trauma centre, which meets the clinical care provision criteria in Australasia, are university-affiliated centres with extensive training and research programme. It is confusing that some Australian trauma centres informally call themselves as Level-2 based on the fact that they do not have all subspecialties to provide definitive care to all trauma patients. Third, the surgical specialties have to be aware of this programme and be committed to set their specialty minimum standards in trauma care together with the Trauma Verification Subcommittee. During the last year, the Orthopaedic Trauma Society proposed the inclusion of the orthopaedic trauma surgeons into the verification site visit teams. Orthopaedic trauma surgery is the most frequent operative intervention on major trauma patients and needs to be optimally resourced at all levels of care. This includes, but is not limited to, adequate emergency and planned daytime acute list for the timely management of the musculo-skeletal injuries. Similarly, other surgical specialties need to have their suggestions on how to optimize the trauma care within their area of expertise. I recommend to all surgeons who are involved into trauma care in the public system to feedback their trauma-related resource requirements to the trauma services of their institution or broader trauma system. The trauma services need to promote the verification process through hospital and health service administration. Trauma verification is a powerful tool to make positive changes through peer review and it bypasses the conflicts of the verified institution’s administration and its employees (surgeons) in quality improvement. ANZ J Surg 84 (2014) 499–501
500
Reference 1. Leonard E, Curtis K. Are Australian and New Zealand trauma service resources reflective of the Australasian Trauma Verification Model Resource Criteria? ANZ J. Surg. 2014; 84: 523–7.
Editorials
Zsolt J. Balogh, MD, PhD, FRACS Trauma Service, Division of Surgery, John Hunter Hospital & University of Newcastle, Newcastle, New South Wales, Australia doi: 10.1111/ans.12573
Enhanced Recovery After Surgery and laparoscopic colorectal surgery: where to now? The presence of a mindset in surgery can have a profound effect, both good and bad. Witness the accepted ‘armchair’ surgery pre-1970 where ‘the boss’ wrote what he/she believed in a textbook, and others simply followed. That was the pre-evidence-based era, and how foreign it now seems. In colorectal surgery, there are numerous notable examples of mindsets. In the early days of low rectal excision and colo-anal anastomosis for cancer, the focus was on post-operative morbidity and oncological outcomes; function was largely ignored, and continence was assumed to be universally satisfactory.1 This mindset changed after the introduction of ileoanal pouch surgery for ulcerative colitis, where function was a natural outcome measure, and this in turn became recognized as important in rectal cancer surgery.2 The introduction of laparoscopic colorectal surgery fortunately occurred in the era of evidence-based medicine. This led to a rigorous process in evaluation of the safety and efficacy of laparoscopic colon resection, showing reproducible improvement over open surgery in short-term outcomes including post-operative morbidity and hospital length of stay,3,4 without compromising oncological outcomes in appropriately selected patients. In tandem with the evolution of laparoscopic colorectal surgery, attempts were being made to reduce the profound physiological response to open colorectal surgery. Initially called Fast Track Surgery by Kehlet5 and later Enhanced Recovery After Surgery (ERAS), it has been shown to significantly accelerate post-operative recovery and reduce morbidity and hospital length of stay.6 Given the improvements seen with laparoscopic surgery, some have wondered whether ERAS would provide a similar magnitude of benefit when applied to laparoscopic surgery as it did with open surgery. Although there are a number of trials with ERAS and laparoscopic colon surgery, few have examined the true effect of ERAS independent of the laparoscopic approach. In addition, there are considerable difficulties interpreting the data. Most studies do not include all of the 15 elements which make up the ERAS protocol, and in the six randomized trials included in a systematic review,7 a mean of only nine ERAS elements were used in the protocols, making it difficult to know the relative contribution of each element. Furthermore, patients and observers are not blinded to treatment using ERAS, and there is little information on patients lost to follow-up with only one study reporting results on an intention-to-treat basis.8 In his Perspective in the April issue of ANZ Journal of Surgery,9 Andrew Hill acknowledges these difficulties, but points out that emerging data may indicate that when ERAS is combined with laparoscopic surgery the greatest benefits are seen.10 Despite this
positive result and that in another recent study,11 it is necessary to continue to examine what effect ERAS has in laparoscopic surgery, as Shaikh and colleagues do in the current issue of the Journal.12 They question the importance of ERAS in laparoscopic colon surgery, given the benefits already derived from the laparoscopic approach. Shaikh’s own study has the obvious deficiencies inherent in a retrospective comparison of unmatched groups, but the important message in the paper is that the authors have shown that with diligent laparoscopic surgery without ERAS they can achieve a short length of stay (mean 5.60 ± 3.83 days in patients without a stoma) with low morbidity and readmission rates. The problem with assessing the true effects of overlaying ERAS on laparoscopic surgery is that the mindset of surgeons has changed so dramatically. Whereas little more than a decade and a half ago, such practices as avoidance of nasogastric tubes, early introduction of oral fluids and solids, short incisions, avoidance of prolonged parenteral narcotic analgesia, and detailed preoperative counselling were uncommon in many places, these elements of ERAS have become routine care in open and laparoscopic surgery. Other elements such as avoiding bowel preparation, early catheter removal and active early mobilization are also commonplace. Whether introduction of other ERAS measures such as preoperative probiotics and carbohydrate load leading right up to surgery, and changes in anaesthetic practice including short-acting agents and thoracic epidurals can be incorporated into routine practice without introducing formal supervised ERAS protocols remains to be seen. In the meantime, other trials are needed. In this issue of the Journal, Kim and colleagues assess the use of intravenous lignocaine in looking for ways to prevent vomiting in patients undergoing laparoscopic colon surgery who do not tolerate early oral feeding.13 In the UK, the ongoing EnROL Trial (Enhanced Recovery Open versus Laparoscopic) is a randomized trial in about 200 patients recruited in 12 hospitals, where patients and outcome observers are blinded to treatment. The trial will compare outcomes in patients undergoing elective laparoscopic and open colorectal surgery embedded in an ERAS program, and the primary outcome measure will be post-operative fatigue, the symptom that has largely been ignored in colorectal trials, but which Andrew Hill in his Perspective9 has pointed out is so important. Colorectal surgeons will continue to examine ways to reduce hospital length of stay as well as time to full recovery and return to work, and advances in minimally invasive surgery, programs such as ERAS, and changes in mindsets will all play a role. © 2014 Royal Australasian College of Surgeons
Trauma verification: for the trauma centre or for the trauma system? This month’s issue of the ANZ Journal of Surgery presents a paper about the potential hurdles in meeting the resource requirements of Trauma Verification Program.1 It is timely to update and reassess the needs when the actual programme is also going through changes. Trauma centres are ‘designated’ by state or federal government but this does not necessarily mean that these institutions meet criteria of optimal care delivery of injured patients according to the standards of trauma surgical professional body of the country. Beyond designation, trauma centres have to be also ‘verified’ to ensure the optimal medical care provision. The Trauma Verification Program is one of the Royal Australasian College of Surgeons Trauma Committee’s most important activities, which has enormous, almost immediately visible impact on trauma care delivery. The Australasian Program was developed based on the Trauma Verification Program of the American College of Surgeons Committee on Trauma. The fundamental difference between the two programmes is that the Australasian verification is performed by a multidisciplinary team (general surgery, orthopaedic surgery, intensive care, emergency medicine and trauma nursing) while the American programme is run by surgical peer-review. The principle of peer review-based benchmarking of the trauma centres is a powerful tool to show hospital/health service administration the potential strengths and weaknesses of individual institutions’ trauma care delivery. Our trauma verification programme started under the chair of Dr Jim McGrath in 2000 with a Royal Australasian College of Surgeons grant for 24 months of pilot of six consultative visits. Forty-four site visits have been undertaken to 32 different hospitals during the last 14 years. Usually, a hospital requests a consultative visit first, which identifies needs for improvements, and is followed by a formal verification visit within a set time frame resulting in an outcome of yes or no. To date, in Australia there are only six hospitals (Liverpool, John Hunter, St George, Royal Perth, Royal Melbourne and Royal Brisbane and Women’s in chronological order) that are verified as level-1 trauma centre. Personally, I consider this is a very slow uptake. The Australasian Trauma Verification Program is currently being reviewed and updated to address the changes that occurred during the last 14 years. There are few key points need to be considered. I believe the first and most important is to shift the aim of the Programme from verifying individual trauma centres to verifying trauma systems. Level-1 (24/7 ability to look after any injured patients with education, research and quality assurance programme) trauma centres can perform well on the verification process individually while the entire trauma system (the network of lower level trauma hospitals, pre-hospital care, inter-hospital transfer arrangements, outreach education programme) could have major insufficiencies. Also, the need and the role of individual Level-1 trauma © 2014 Royal Australasian College of Surgeons
centres will be more obvious with this approach. Some of our states are struggling with establishing their trauma system. Victoria is the usual positive example with its highly centralized system and documented improvements in outcomes, but even there only the Level-1 trauma centres had formal or consultative verification visits. Capital cities like Perth, Adelaide and Sydney have either unclear or suboptimal pre-hospital transport arrangements or far too many designated Level-1 trauma centres per population. The integration of the Australian Capital Territory into the New South Wales trauma system needs to be formalized and based on medical rather than political priorities. The independent interstate and international peer review can help to facilitate these fundamental changes. The good examples where a larger geographic area or trauma system was reviewed so far were Northern Territory (2004), Queensland (2009) and Midland Region in New Zealand (2013). The second important change that has to happen is the adjustment of the trauma centre definitions to the Australasian specifics rather than simply adopt the North American criteria. The best example to this is that the Level-2 trauma centre (24/7 ability to treat definitively any trauma patients but no formal academic affiliation and teaching/ research) is not an existing model in our countries. Any designated trauma centre, which meets the clinical care provision criteria in Australasia, are university-affiliated centres with extensive training and research programme. It is confusing that some Australian trauma centres informally call themselves as Level-2 based on the fact that they do not have all subspecialties to provide definitive care to all trauma patients. Third, the surgical specialties have to be aware of this programme and be committed to set their specialty minimum standards in trauma care together with the Trauma Verification Subcommittee. During the last year, the Orthopaedic Trauma Society proposed the inclusion of the orthopaedic trauma surgeons into the verification site visit teams. Orthopaedic trauma surgery is the most frequent operative intervention on major trauma patients and needs to be optimally resourced at all levels of care. This includes, but is not limited to, adequate emergency and planned daytime acute list for the timely management of the musculo-skeletal injuries. Similarly, other surgical specialties need to have their suggestions on how to optimize the trauma care within their area of expertise. I recommend to all surgeons who are involved into trauma care in the public system to feedback their trauma-related resource requirements to the trauma services of their institution or broader trauma system. The trauma services need to promote the verification process through hospital and health service administration. Trauma verification is a powerful tool to make positive changes through peer review and it bypasses the conflicts of the verified institution’s administration and its employees (surgeons) in quality improvement. ANZ J Surg 84 (2014) 499–501
500
Reference 1. Leonard E, Curtis K. Are Australian and New Zealand trauma service resources reflective of the Australasian Trauma Verification Model Resource Criteria? ANZ J. Surg. 2014; 84: 523–7.
Editorials
Zsolt J. Balogh, MD, PhD, FRACS Trauma Service, Division of Surgery, John Hunter Hospital & University of Newcastle, Newcastle, New South Wales, Australia doi: 10.1111/ans.12573
Enhanced Recovery After Surgery and laparoscopic colorectal surgery: where to now? The presence of a mindset in surgery can have a profound effect, both good and bad. Witness the accepted ‘armchair’ surgery pre-1970 where ‘the boss’ wrote what he/she believed in a textbook, and others simply followed. That was the pre-evidence-based era, and how foreign it now seems. In colorectal surgery, there are numerous notable examples of mindsets. In the early days of low rectal excision and colo-anal anastomosis for cancer, the focus was on post-operative morbidity and oncological outcomes; function was largely ignored, and continence was assumed to be universally satisfactory.1 This mindset changed after the introduction of ileoanal pouch surgery for ulcerative colitis, where function was a natural outcome measure, and this in turn became recognized as important in rectal cancer surgery.2 The introduction of laparoscopic colorectal surgery fortunately occurred in the era of evidence-based medicine. This led to a rigorous process in evaluation of the safety and efficacy of laparoscopic colon resection, showing reproducible improvement over open surgery in short-term outcomes including post-operative morbidity and hospital length of stay,3,4 without compromising oncological outcomes in appropriately selected patients. In tandem with the evolution of laparoscopic colorectal surgery, attempts were being made to reduce the profound physiological response to open colorectal surgery. Initially called Fast Track Surgery by Kehlet5 and later Enhanced Recovery After Surgery (ERAS), it has been shown to significantly accelerate post-operative recovery and reduce morbidity and hospital length of stay.6 Given the improvements seen with laparoscopic surgery, some have wondered whether ERAS would provide a similar magnitude of benefit when applied to laparoscopic surgery as it did with open surgery. Although there are a number of trials with ERAS and laparoscopic colon surgery, few have examined the true effect of ERAS independent of the laparoscopic approach. In addition, there are considerable difficulties interpreting the data. Most studies do not include all of the 15 elements which make up the ERAS protocol, and in the six randomized trials included in a systematic review,7 a mean of only nine ERAS elements were used in the protocols, making it difficult to know the relative contribution of each element. Furthermore, patients and observers are not blinded to treatment using ERAS, and there is little information on patients lost to follow-up with only one study reporting results on an intention-to-treat basis.8 In his Perspective in the April issue of ANZ Journal of Surgery,9 Andrew Hill acknowledges these difficulties, but points out that emerging data may indicate that when ERAS is combined with laparoscopic surgery the greatest benefits are seen.10 Despite this
positive result and that in another recent study,11 it is necessary to continue to examine what effect ERAS has in laparoscopic surgery, as Shaikh and colleagues do in the current issue of the Journal.12 They question the importance of ERAS in laparoscopic colon surgery, given the benefits already derived from the laparoscopic approach. Shaikh’s own study has the obvious deficiencies inherent in a retrospective comparison of unmatched groups, but the important message in the paper is that the authors have shown that with diligent laparoscopic surgery without ERAS they can achieve a short length of stay (mean 5.60 ± 3.83 days in patients without a stoma) with low morbidity and readmission rates. The problem with assessing the true effects of overlaying ERAS on laparoscopic surgery is that the mindset of surgeons has changed so dramatically. Whereas little more than a decade and a half ago, such practices as avoidance of nasogastric tubes, early introduction of oral fluids and solids, short incisions, avoidance of prolonged parenteral narcotic analgesia, and detailed preoperative counselling were uncommon in many places, these elements of ERAS have become routine care in open and laparoscopic surgery. Other elements such as avoiding bowel preparation, early catheter removal and active early mobilization are also commonplace. Whether introduction of other ERAS measures such as preoperative probiotics and carbohydrate load leading right up to surgery, and changes in anaesthetic practice including short-acting agents and thoracic epidurals can be incorporated into routine practice without introducing formal supervised ERAS protocols remains to be seen. In the meantime, other trials are needed. In this issue of the Journal, Kim and colleagues assess the use of intravenous lignocaine in looking for ways to prevent vomiting in patients undergoing laparoscopic colon surgery who do not tolerate early oral feeding.13 In the UK, the ongoing EnROL Trial (Enhanced Recovery Open versus Laparoscopic) is a randomized trial in about 200 patients recruited in 12 hospitals, where patients and outcome observers are blinded to treatment. The trial will compare outcomes in patients undergoing elective laparoscopic and open colorectal surgery embedded in an ERAS program, and the primary outcome measure will be post-operative fatigue, the symptom that has largely been ignored in colorectal trials, but which Andrew Hill in his Perspective9 has pointed out is so important. Colorectal surgeons will continue to examine ways to reduce hospital length of stay as well as time to full recovery and return to work, and advances in minimally invasive surgery, programs such as ERAS, and changes in mindsets will all play a role. © 2014 Royal Australasian College of Surgeons
