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Future Directions

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Trauma Registries,
Service development and
Research
Professor Peter Cameron
Academic Director
Alfred Emergency and Trauma Centre
National Trauma Research Institute
Monash/Alfred Injury Network (MAIN)
Monash University
Outline
● What we have done in Victoria
● Population based monitoring
● Patient centred outcomes
● Cost
● Prevention

● Where are our gaps
● Where are the opportunities
● Service development
Population approach?
● Danger in measuring hospital mortality alone
● Disability
● Complications
● Cost
● Patient experience

● Has been difficult to measure in the past….
Review Of Trauma and Emergency Services
(ROTES Report 1999)
• Ministerial Taskforce established 1997, report published 1999
• Pre-hospital guidelines (bypass)
• Transfer guidelines
• Role delineation
• Essential, desirable, not applicable features
• Designation of health services to fulfill specific roles
• Process of audit and monitoring of outcomes from trauma
care
• Recommendations aimed at achieving optimal outcomes
through coordinated trauma care
• “The right patient to the right hospital in the shortest time”
Implementation
● Sustainable funding
● Governance
● Structures
● Data

● No mention of Patient centred outcomes…..
A Systems Approach?
• Essential for quality outcomes
• Integrated
– Prevention
– Roadside to recovery
– Non Major Trauma services included

• System governance structure
– Oversight
– Funding
– resources

• System wide monitoring
– Roadside to Recovery
– Monitoring integrated into governance
Integration
● Not only patients going to MTS
● Need all health services designated
● Training and monitoring even for peripheral hospitals
● In Victoria – 130 health services!
● Need prehospital triage and trauma bypass
● Integrated transport platforms
● Private transport
● Road ambulance
● Helicopter/fixed wing
Trauma Systems
Prior to Trauma System - <50% of patients had
definitive treatment at an MTS
Now >85%
For RTC >90%
Governance
● Requires
● System wide authority
● Trauma Service Designation
● Monitoring
● Clinical expertise
● Representation of all services

● Most trauma systems and most trauma registries don’t
have system wide governance
Governance
Context
● 6 million
● Statewide, integrated, inclusive trauma
system
● Routine data collection systems
• VACIS
• VAED
• VEMD
• Deaths/Coroners
• Insurance data
• Vic Crash data
• Victorian State Trauma Registry
(VSTORM)
• Victorian Orthopaedic Trauma
Outcomes Registry (VOTOR)
VSTR In-hospital death rates
(AOR - ISS, HI, Age, Mechanism)

*The data from the Victorian State Trauma Registry was provided by VSTORM, a Department of Health and Transport Accident
Commission sponsored project.
Population descriptor Adjusted odds p-value
ratio (95% CI)
Definitive management Major trauma service (reference) 1.00
Other 0.82 (0.69,0.97) 0.021
Year injured October 2006-June 2007 (reference) 1.00
July 2007-June 2008 1.22 (1.05,1.41) 0.010
July 2008-June 2009 1.16 (1.01,1.34) 0.040

*of injury and pre-injury work status adjusted for age, gender, injury severity, preinjury disability, level of education, compensable
status, comorbid status, intent of injury, mechanism

(Gabbe et al. Ann Surg 2012;255:1009-1015)
What about patient experience??
What happens after Discharge
Counts!!
Evidence for Management of
Recovery
● No RCTs on Rehabilitation
● No RCTs on effect of compensation
● Hard to believe that the only influence on trauma
outcomes occurs in first few hours……..
What about cost??
Reduction in Cost
● Reduction in overall burden of road traffic injury measured
in DALYs for hospitalised major trauma of 28%

● Estimated cost per year dropped using Value of Statistical
Life Year (VSLY) from AUD$ 1.85 billion to AUD$1.34 billion
per year over 10 years
Cost of Injury
The Quality Cycle
● Plan Do Study Act
● Benchmark
● Compare and Adapt

● Need adequate governance and
a system approach for this to
occur
Injury Prevention
What do we need to do better
● Benchmarking
● ATR
● At a national level in Australia
● Has been difficult
● International
● Working with UK/USA/Germany/HK
● Many other countries
● Quality Indicators
● Much work – poor indicators

● Using the Registry for research
● Single points of follow up for trials
● eg TBI studies
Following patients over time
● Restore study
● Up to 5 years
RESTORE project
● 2,424 adult major trauma patients with a date of injury from 1 July
2011 to 30 June 2012

● Captured by the Victorian State Trauma Registry

● Survived to hospital discharge

● Follow-up of all patients at 6, 12, 24, 36, 48 and 60 months post-injury
● EQ-5D-3L, GOS-E, Return to work, CHIEF, IES-R

● Linkage to hospitalisations, mental health, drug and alcohol treatment
data

● Nested longitudinal qualitative component

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Mortality Post discharge
Recovery Trajectory for TBI
● Isolated head injury – GOSE significantly worse from 24 to
36 months

● Return to work deteriorates significantly 24 to 36 months
● Different from other injury groups
● Why??
Where to with all this?
● With a good trauma system – trauma deaths decrease
● I suspect that specific Rx variations make little difference

● Function post discharge improves to 2 years
● Head Injuries decreasing overall
● But major increase in elderly….
● However
● Significant mortality post discharge
● Very different recovery trajectories for TBI
● Uncertain what makes a difference to recovery?
Influences on post injury
recovery
● Inpatient/outpatient rehab…..therapists?
● Compensation/legal issues
● Family/environment
● Pain
● Anxiety/depression…..
● ie – everything other than what an emergency physician
knows about!!
● This is about social science/physio/OT/etc
Trauma is increasingly a disease of
the aged
Proportion of deaths by age
Prehospital Deaths??
● Continuity of care and “pathways” are often discussed
● Hospital doctors only see the pt after the “golden hour”
● What happens at the scene
● Dispatch/notification
● eg Automatic 000 call with crash?
● Scene control
● Too slow?
● Scene interventions
● Novel?
● Transport
● Logistics/helicopters?
Prehospital Deaths
● Currently Victoria is reviewing all trauma deaths
prehospital
● With a 2017 lens
● Better notification?
● More skills at scene?
● More interventions prehospital?
Questions on specific
interventions
● Basic Questions
● Oxygen/temperature
● Fluid
● Cervical collars/immobilisation
● Transfusion regimens
● Monitoring of coagulation at bedside
● Haemorrhage control
● Procoagulants – local /systemic
● Embolisation
● Reboa etc
Questions on specific
interventions
● Orthopaedics
● Fixation/prostheses
● Neurosurgery
● Decompressive craniectomies?
● RESCUE-ICP vs DECRA
● Spinal Cord Injury
● ICED
● No drug so far has limited injury of neurons
● Chest
● Rib fixation?
Where do we fit our other QI
activities
●M+M
●Sentinel Events
●Admitted Episode Data
●Coronial Data
●Process/Activity Data

●The registry acts as an Anchor Point
●Robust data, credible to clinicians
Conclusion
● Trauma Registries are the key to optimising trauma systems
● Victoria has developed an integrated trauma system - Australia is
finally developing a national approach

● Trauma Registries enable a systematic approach to research –
especially post hospital recovery outcomes
● For most trauma conditions – a multi centre/regional collaboration
necessary for numbers

● Trauma still kills more young people than any other disease
● High rates of disability persist post discharge
● Very few jurisdictions have a true systems approach
● Tamil Nadu could quickly implement a regional approach