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Future Directions -

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 dont


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