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The Alfred

&
The Victorian State Trauma System
Professor Mark Fitzgerald ASM
MBBS MD FACEM AFRACMA
Director of Trauma Services
Director National Trauma Research Institute
Professor, Department of Surgery, Central Clinical
School, Monash University
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The Alfred Trauma Service
• 8,000 trauma admissions per year
• 1,400 major trauma patients

ISS>12

2
27 June 2017 3

By 2020 Trauma (physical injury) will be No. 3 on
the WHO list - Global Burdens of Disease
• 1.25 million died globally from road trauma alone in 2013

7% increase in Victorian road deaths in 2016
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In India, road crashes are the commonest cause
of death for people under the age of 35.

The estimated cost of road crashes in
India is 2% of the GNP

~USD $37,540,000,000

>150,000 killed in road crashes annually
In India, road crashes are the commonest cause
of death for people under the age of 35.

76% of road trauma
deaths after hospital
admission considered
unexpected
Goel A, Kumar S, Bagga MK.
Epidemiological and Trauma Injury and
Severity Score (TRISS) analysis of trauma
patients at a tertiary care centre in India. Natl
Med J India. 2004 Jul-Aug;17(4):186-9.
Lucknow
27 June 2017

Decade of Action for Road Safety 2011-2020

Goal - to stabilize and reduce the forecast level of
road traffic deaths around the world.

• Pre-hospital care systems development
• Hospital trauma care systems development
• Early rehabilitation and support to injured patients
• Establishment of appropriate road user insurance schemes
• Encourage research and development
27 June 2017 7

per 100,000 per 100,000 annual

persons vehicles deaths
China 20.5 133.3 275,983 2010
India 19.5 207.5 238,562 2013
Nigeria 33.7 425.2 53,339 2010
Brazil 22.5 67.7 43,869 2010
Indonesia 17.7 58.4 42,434 2010
United States 11.6 13.6 36,166 2012
Australia 5.6 7.6 1299 2012
Worldwide approximately 16,500 people die each day
from injuries, including 6,000 who bleed to death.

Haemorrhage is responsible for over
35% of pre-hospital trauma deaths
and over 40% of trauma deaths
within the first 24 hours.
27 June 2017 9

In the 1990’s Victorian medical professionals began
publishing data which demonstrated that 30-40% of
deaths were preventable of potentially preventable…
• Multidisciplinary Panel review of care of all
road fatalities over several years
• Focus on Preventable Deaths
• 30 - 40% of deaths were preventable or
potentially preventable
• Problems were identified in the management of
all types of injuries, and at all stages of pre-
hospital and hospital care
Prof. Frank McDermott
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ABCs and Sustainability

Local relevance
Governance
Measurable outcomes
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Goals of the Victorian State Trauma System

To deliver the right patient to the right hospital in
the shortest time

To best match Victorian resources with patients’
needs ensuring the delivery of optimal care

Preprogrammed response with rapid transfer to
a Major Trauma Service
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Victorian State Trauma System

• Prevention
• Preprogramed response
• Reduce secondary insults
‘pre’ and ‘in’ hospital
• Rapid transfer to a Major
Trauma Service
• The ‘right patient to the right
people in the right time’

‘The Evolution of an Integrated State Trauma System in Victoria, Australia.’ Chris Atkin, Ilan Freedman, Jeffrey V. Rosenfeld, Mark
Fitzgerald, Thomas Kossmann. Injury; 36(11):1277-1287, November 2005.
Victorian State Trauma Registry - Distribution of Major Trauma*:
Definitive Care (Financial Years)
The data from the Victorian State Trauma Registry was provided by VSTORM, a Department of Health and Human Services and Transport Accident Commission funded project.
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10 year trend for trauma activity – 2020 predicted
 Major trauma from 4 to 6 patients per day
20,000
17,761

15,000

10,498
10,000
8,357

5,000
2,100 2,141

0
Total Injury
ISS>12 Major Non-Major
Admissions Attendances
FY2006 807 944 3,867 4,811 12,528
FY2012 925 1,132 5,399 6,531 15,682
FY2016 1,260 1,409 6,593 8,002 17,685
*2020 2,100 2,141 8,357 10,498 17,761
*Pre FY2014 reported ISS98 >15
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The major variable in resuscitation
relates to human factors.
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CT Scans
x 50k

OECD 2009
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Odds of in-hospital death of major trauma patients
since introduction of the Victorian State Trauma System
Adjusted for injury severity, age and head injury
Source: Victorian State Trauma Registry
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Trauma systems reduce mortality and morbidity

Mock CN, Adzotor KE, Conklin E, Denno DM, Jurkovich GJ. Trauma
outcomes in the rural developing world: comparison with an
urban level I trauma center. J Trauma. 1993; 35: 518-23.
= Reduction in mortality compared to no
trauma system

Cameron PA, Gabbe B, Cooper DJ. A statewide system of trauma
care in Victoria: effect on patient survival. Med J Aust. 2008; 189:
546-50.
= Reduction in mortality over time

Gabbe BJ, Simpson PM, Sutherland AM, Wolfe R, Fitzgerald MC,
Judson R, Cameron PA. Improved functional outcomes for major
trauma patients in a regionalized, inclusive trauma system. Ann
Surg. 2012; 255(6): 1009-15.
= Reduction in disability
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Trauma management
Risk reduction and error avoidance

James K Styner
Nebraska 1976
Journal of Trauma Nursing
June 2006, Volume :13 Number 2,
page 41- 44
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Trauma management
Risk reduction and error avoidance

Crew Resource management grew
out of the 1977 Tenerife airport
disaster where two Boeing 747
aircraft collided on the runway
killing 583 people
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Trauma care versus the Airline industry

risk

time
27 June 2017 24

Surgery / Operative
Care Pre-Hospital
Care

Emergency / Critical
Care

Physical / OT/ Rehab
Care
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Trauma – a quaternary speciality

Surgery / Operative
Care
Injury evolution, timing of presentation,
timeliness of intervention, time
management & coordination of resources

Physical / OT/ Rehab
Care
Emergency / Critical
Care
Pre-Hospital
Care

25
27 June 2017 26

Research in Trauma
Severe Pelvic Injury

25% 180

160

20%
140

120

15%
100
Mortality Pts.

80
10%

60

40
5%

20

0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
0
Pts 51 48 71 85 124 98 121 133 117 100 108 156
% Mortality 20% 17% 13% 16% 11% 7% 10% 5% 6% 8% 6% 8%
2002 2013 27 June 2017 27

(n=51) (n=156)
Age at presentation 42.7 (20.2) 48.2 (22.4) 0.13
(years)
Male sex 34 (67%) 93 (60%) 0.71
Time to hospital 119 (227) 112.3 (66) 0.72 Variable Adjusted OR 95% CIs p-value
(minutes)
Max Pelvic AIS 0.72
Year 2013 0.10 (0.02-0.60) 0.01
- 3 37 115 Age 1.05 (1.01-1.09) 0.01
- 4 12 31
2 10 ISS 1.08 (0.99-1.17) 0.08
- 5
Max head AIS ≥ 3 14 (27.4%) 32 (20.5%) 0.30 ICU Admission 0.24 (0.04-1.40) 0.11
Systolic BP on TCA 123 (37) 132 (33.7) 0.12 SI≥1 3.9 (0.63-24.5) 0.14
Mean Heart Rate on TCA 99 (28) 95 (25) 0.31 Heart rate >100 b/min 0.37 (0.04-3.13) 0.36
Systolic BP < 100 mmHg 7 (14%) 19 (12%) 0.74 Head AIS≥ 3 1.2 (0.52-2.7) 0.69

Table 2. Independent associations with
Heart Rate > 100/min TCA 22 (43%) 48 (31%) 0.09
mortality at hospital discharge
ISS: Injury Severity Score; ICU: Intensive Care
SI≥1 13 (25%) 25 (16%) 0.10 Unit; AIS: Abbreviated Injury Scale
ISS 29 (13-41) 22 (13-36) 0.78
Proportion requiring ICU 25 (49%) 72 (46%) 0.72
admission
Any blood transfusion 22 (43%) 67 (42%) 0.98

Table 1: Serious (AIS>3) pelvic injury
presentations 2002 and 2013.
AIS: Abbreviated injury scale; BP: blood pressure; SI:
Shock index; ISS: Injury Severity Score; ICU: Intensive
Care Unit
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The impact of inclusive, integrated Trauma
Systems
People with life-threatening - but
potentially treatable - injuries are up
to six times more likely to die in a
country with no organized trauma
system than in one with an
organized, resourced trauma
system.

Mock CN, Adzotor KE, Conklin E, Denno DM,
Jurkovich GJ. Trauma outcomes in the rural
developing world: comparison with an urban level I
trauma center. Journal of Trauma 1993;35:518-23.
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A single intervention in a mature Trauma System or…?

the TR&R hypothesis

‘..The greatest improvements in resuscitation
will come with improved team communication,
standardization of interventions, improved
physiological monitoring, adherence to
algorithmic treatment pathways and the
associated reduction in errors of omission…’
15/12/2015
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Discharge Destination – Major Trauma
1600
1400
1200
1000
800
600
400
200
0 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016
Home 369 450 420 508 533 507 571 584 534 488 622
Rehab/other acute 461 564 552 522 511 481 534 554 599 599 608
Died 102 122 122 104 112 100 105 111 118 115 144
Other 18 23 29 33 88 44 53 44 24 57 35

Trauma Service & NTRI Audit 2014-2015
NTRI & Alfred Health Trauma Activities in the Region 31
CHINA
INDIA
LongGang Peoples’ Hospital & LongGang Central Hospital - trauma
Trauma Registry Development – Odisha
reception and resuscitation training, bilateral medical & nursing exchange,
Trauma System advocacy & Development – Kerala, Punjab, Tamil Nadu
Trauma care support during World University Games in 2011
Development of Trauma system registry, centre and education – Punjab
Southwest Hospital, Third Military Medical University, Chongqing
Trauma Reception and Resuscitation (TR&R) Advanced Training Program – Punjab
Development of Burns registry based on Bi-National Burns Registry in
Australia-India Trauma System Collaboration – JPN Apex, AIIMs
Australia
MOU between NTRI/Alfred and Ministry of Health and Family Welfare
Qiqihar – Critical Care and surgical exchange program
Huizhou – Trauma System and Trauma Centre establishment

IRAN
WHO Trauma Quality MYANMAR
Improvement Program Short Trauma Registry Development
Course Medical & Nursing Training
Trauma System Plan

SAUDI ARABIA
KSMC Trauma Center and
Research Institute

VIETNAM
ETHIOPIA Medical Services program
WHO Trauma Quality Improvement development in Vietnam
Program Short Course
PHILIPPINES
Australia-Philippine Trauma
Program
AFRICA
Development of African
Federation for Emergency
Medicine Handbook

MALAYSIA
WHO Trauma Quality Improvement
Program Short Course

WHO Global Alliance for Care of the Injured
Asia –Pacific Trauma Quality Improvement SRI-LANKA
Network Trauma Quality Improvement training AUSTRALIA
WHO Checklist Trauma Registry Development Various Projects including AusTQIP a
Collaborative Research on trauma system Oversaw building of new E&TC Hospital collaboration of the 27 Australian Major Trauma
development, training, QI & Trauma registries in Galle Services & Australian Trauma Registry
developing countries Ongoing training & advice
Consultancy to Trauma Registry development
27 June
32 2017
9/11/2017 33

Trauma Systems development challenges
the conventional medical hierarchy

Mark Fitzgerald, Jennifer Jamieson, Jin Win Tee, Yashbir Dewan.
Indian Journal of Neurotrauma (IJNT), Vol. 8, No. 2, 2011, pp. 67-70

Challenging the traditional approaches in Medicine (and the
hierarchal vertical system it embodies) requires data, clarity of
purpose and persistence.

However, Medicine is eclectic, adaptive and receptive to adopting
ideas that demonstrate significant improvements in patient outcomes.

The establishment of Trauma Systems is one of those ideas.

International Emergency Care
“It’s been my responsibility to implement regional
trauma networks for major trauma across England. I
am truly indebted to the work that’s been done in
Victoria, and I have been very grateful for the ability to
be able to copy and to use many of the lessons that
you have learned.

I am sure I will not be alone in recognising the
Professor Keith Willett enormous contribution the Victoria State Trauma
National Clinical System has made to the improvement in care for
Director for Trauma trauma worldwide.”
Care 2011-2013,
NHS England.
Great Innovations of the 21st Century -
Integrated Trauma Systems and the
The Tamil Nadu Trauma System
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m.fitzgerald@alfred.org.au