North American trauma systems are incredibly critical for the care of injured patients yet they vary greatly across the United States and Canada. Trauma is a very common occurrence because these countries are highly industrialized and there is a plethora of private transportation. It is estimated that >50% of hospitalized trauma patients have one or more musculoskeletal injuries. Around 16,000 Canadians die every year from trauma (about 43 per day) making it the number one killer for people under 45 in this country. In the United States, most isolated fractures can be treated by an orthopaedic surgeon with experience in fracture care, but patients with multiple fractures, fractures associated with other system injuries, complex fractures such as pelvic, acetabular, or fractures with a significant soft tissue injury are more appropriate candidates for musculoskeletal trauma care in a higher level trauma center. In this article, the composition of trauma systems and the practical delivery of this care will be presented for North America.
2 Trauma systems in the United States
Currently in the United States, there is neither a unified national trauma system nor is there a national standard defining how a trauma center becomes designated as such despite evidence that demonstrates better outcomes and coordination of care.[2–4] Efforts to establish a national trauma system are being led by the American College of Surgeons Committee on Trauma (ACS COT). The ACS COT has developed a coalition to implement the National Academy of Sciences, Engineering and Medicine's 2016 report entitled, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. The leadership of the ACS COT has made great progress in achieving the reality of a national trauma system, but until such a national system is established, the current responsibility of coordinating a trauma system and the process of how a medical center is designated a trauma center varies in each state and is outlined through legislative or regulatory authority.
The ACS COT is the national entity that focuses on improving the care of the injured patient. The ACS COT was founded in 1922 and has grown into an organization that focuses on a multidisciplinary approach to the care of the trauma patient at the local and national level. With this charge, the ACS COT first published criteria in 1976 as to the standards needed, both in resources and personnel, for the optimal care of the trauma patient at a designated trauma center. Beginning in 1987, the ACS COT began a program to verify hospitals in the United States that meet the criteria outlined to be a successful trauma center. As stated in its mission, the verification process intends “To create national guidelines for the purpose of optimizing trauma care in the United States. This objective may be accomplished through a voluntary review of potential and existing trauma centers so that trauma centers may provide an organized and systemic approach to the care of the injured patient.” This verification process, which is administered by the Verification, Review, and Consultation (VRC) Program, is designed to help hospitals improve trauma care. This process involves the completion of a prereview questionnaire and a VRC site visit, which leads to a report of findings and recommendation to verify or not. If successful, the trauma center receives a certificate of verification that is valid for three years. It is important to again highlight that the ACS COT Verification, Review, and Consultation Program only verifies that a trauma center meets the criteria outline in the Resources for Optimal Care of the Injured Patient for a specific trauma level designation and does not formally serve as the designating entity at the state level.
Prehospital care is an essential element in the clinical outcome of trauma patients. Emergency medical services (EMS) are managed in a regional basis such that local government agencies direct the resources that are available to care for the injured patient. These resources include ambulance/paramedic, fire, police, and other units. The ACS COT requires verified trauma centers to engage with prehospital personnel to ensure quality and coordination of care.
Prehospital personnel are responsible for the immediate care of the injured patient. These providers perform initial “assessment, extrication, initiation of resuscitation and stabilization, and safe and timely transport to the closest trauma center.” EMS personnel work within the criteria and protocols published in Prehospital Trauma Life Support (PHTLS). Destination criteria are used to ensure that injured patients are taken to the most appropriate center for definitive care. Transport is usually performed by ground ambulance, but helicopters are utilized when available and appropriate. Rapid and decisive care provided by EMS personnel is essential to the optimal outcomes for trauma patients.
The most recent edition of the ACS COT Resources for Optimal Care of the Injured Patient was published in 2014. The Resources for Optimal Care of the Injured Patient defines the responsibility of the orthopaedic surgical team members in the care of the trauma patient and highlights the importance of the partnership of the orthopaedic surgeon with the trauma team leader (TTL) at a verified trauma center. Chapter 9 of the Resources for Optimal Care of the Injured Patient defines the requirements of the orthopaedic service in the care of a trauma patient. This chapter was written by orthopaedic surgeons who are members of the Orthopaedic Trauma Association (OTA) and the ACS COT, and is currently being updated in order to ensure that orthopaedic care of the trauma patient is optimized and conducted in most current evidence based methods.
Trauma centers are designated according to the resources they can apply to the care of the injured patient. Level I and II trauma centers are the most capable of caring for patients with complex life-threatening injuries. According to ACS criteria, “the standards for the provision of clinical care to injured patients for level I and level II trauma centers are identical.” Level I centers have additional requirements to differentiate them from level II. Level I centers must meet admission volume requirements (at least 1200 trauma patients yearly or have 240 admissions with an Injury Severity Score of >15). Level I centers must also maintain critical care service directed by a critical care surgeon. They must participate in the training of residents, lead education and outreach activities and perform research in trauma.
Level II centers exist in metropolitan areas where they augment the care delivered by the level I center or in less populous areas where they serve as the definitive destination for the injured patient. Similar to level I centers, surgeons in level II centers must respond to the trauma patient within 15 minutes of arrival and be involved in “major resuscitations, be present at operative procedures, and be actively involved in the critical care of all seriously injured patients.” Level II centers provide a critical resource in the trauma system through delivering definitive care and augmenting the services of level I centers.
Level III centers provide care to injured patients within the capabilities of their resources and appropriately transfer stabilized patients to level I or II centers when necessary. These centers are essential to the trauma system providing crucial care to injured patients in areas geographically distant from higher level facilities. They must have continuous surgical coverage and trauma programs to improve care. Level IV centers are found in sparsely populated areas and provide initial care to trauma patients in these locales. They provide initial stabilizing care to the injured patient and transfer these patients to higher levels of care.
The Resources for Optimal Care of the Injured Patient book highlights important institutional resources both in staffing and facilities that are needed to ensure the best care of a trauma patient with musculoskeletal injuries. These include having support personnel such as well-trained radiologic technologists, operating room staff, physical and occupational therapists and rehabilitation specialists, social workers, and discharge planners to facilitate the transition of care from the acute care setting to home or another facility. These guidelines also emphasize the importance of the prompt availability of operating rooms to allow for the emergent care of orthopaedic injuries and the flexibility in both operating room and staff scheduling so that musculoskeletal trauma cases can be scheduled without undue delay and not at inappropriate hours. The guidelines also emphasize the requirements of the orthopaedic surgeon providing leadership and care at level I trauma centers, and set criteria that the leader of the orthopaedic trauma division must have finished a fellowship by an OTA approved program. In addition to the institutional requirements, the guidelines emphasize the importance of the partnership of the orthopaedic surgeon and the trauma medical director, and define criteria of what should be the appropriate response of the orthopaedic surgeon to the care of a trauma patient and sets the criteria for regular performance improvement monitoring for certain orthopaedic conditions.
The recognition of a hospital as a “designated” trauma center has many benefits including financial benefits from access to allocated trauma funding sources, reputational benefits by being recognized as a Center of Excellence for trauma care, and in quality benefits because of the commitment to process improvement programs. These benefits are why hospital systems desire to achieve designation as a Trauma Center; however, not all trauma centers are created equal. As noted above, the criteria used to determine if a medical center has the necessary components needed to achieve a certain level of trauma designation varies from state to state without a formally mandated national set of criteria, and thus no set standard for quality and resources.
Some states have begun to require that a trauma center be verified by the most widely recognized and uniform national verification process; the ACS VRC Program. It is important to highlight that this practice is not universal, and many states still set their own criteria for each level of a trauma center which may differ from the requirements of the ACS COT. The criteria for ACS verification are typically more rigorous, and ACS verification as a level I trauma center has been shown to be a predictor of survival compared to centers that are only state-designated level I (not ACS verified).
3 Trauma systems in Canada
Trauma is an important disease process for Canadians. This results in about 3.5 million emergency department visits in a country of 36 million people. Canada has a relatively small and mostly urban population in a geographically immense (second largest in world) country. Most of the landmass of Canada is sparsely inhabited at best. There are level I trauma programs based mainly in larger cities that allow fairly rapid access to tertiary care. Rural areas have small primary-care hospitals staffed by registered nurses or general practitioners. In remote locations, such as the far north, nursing stations may be the only care location for injured patients. These patients can eventually be sent to tertiary trauma centers but often face delays of many hours and may require transport over distances of up to thousands of kilometers. Level I and II trauma centers provide trauma care and in some instances coordinate the efforts of their surrounding trauma systems. Most Canadians reside within one-hour road travel catchments of these centers. Of the 22.5% of Canadians who live more than an hour away from a level I or II trauma center, all are in rural and remote regions. Despite these limitations most injured patients are cared for in trauma centers.
A population-based cohort study was performed for Quebec (second most populous province) including all injured adults admitted to acute care hospitals between 2006 and 2011. Of the 135,653 injury admissions selected, 75% were treated within the trauma system. Among 25,522 patients with major injuries [International Classification of diseases Injury Severity Score (ICISS<0.85)], 90% had access to trauma centers. Access to a trauma center was actually higher for rural patients in this study. This is an artifact of the system outlined above where these patients have no access to any care in many places so are directly transferred to a tertiary center despite the travel time being well beyond the golden hour for treatment.
Dealing with this geographically imposed restriction to timely care has been one of the largest difficulties in delivery of trauma care in Canada. Injury rates and injury mortality rates have been shown to be generally higher in rural and remote communities. Care-delivery deficiencies are multifactorial right across North America. Access to trauma service has been compromised by: limited phone service, incomplete emergency medical services system access, geographical and climate challenges compounded by limited transportation options, airport capabilities and paramedic training level, dysfunctional hospital no-refusal policies, lack of hospital destination policies, and lack of system leadership and coordination. There have been care issues in urban centers as well with a large patient study in Quebec showing problems in access for the elderly, women, and in urban areas where there are many nondesignated hospitals.
The Canadian system does not have unlimited coverage as widely believed nor does it have the financial freedom to overcome many of these issues. Canada is world renowned for its single payer universal health coverage. In actuality, only about 70% of the medical acts are paid through the government-funded health care system. There is a fairly robust, but not spoken of, private system for rehabilitation services, radiology and other procedures or medication packages. Since the 1960s, the Canada Health Act has dictated a universal care policy to be observed in each province, although individual provinces have freely interpreted portions of the act. The act also provides federal transfer payments to the provinces to smooth out interprovincial differences. Budget rollbacks and further urbanization over the last few decades have resulted in consolidation of health services and regionalization of trauma care generally into large urban university centers. Despite there being national legislation in place dictating universal health care; health is a provincial responsibility and each province funds and administers its own health services out of provincial budgets.
One strong aspect of the Canadian system is that following a terrible personal tragedy, no one is faced with huge medical bills to interfere with the rehabilitation process. This is probably where the universal system concept works the best. However, in elective surgery areas, the wait times have grown substantially—up to 2 years or more in some subspecialties—making it difficult for patients with disabling conditions to obtain care.
Prehospital care is very different for each province and its regions, as most provinces have large, nearly uninhabited spaces. For trauma care and other acute disease processes, most of the country is served by air-ambulance services administered by the provincial and territorial ministries of health. The country at large, therefore, is superficially served by a similar system to that seen in other G7 countries. However, pickups and transfers between provinces may have some legislative and therefore practical difficulties. Aircraft transfer is available to remote patients for transport over long distances that tie into local services at point of care. Most provinces have a well-run EHS Helicopter service that reduces the transfer time efficiently. These vary from fixed wing aircraft and helicopter dedicated air-ambulance services to ground ambulances. No helicopter service reflects a decision by government of province not to pay for it. Quebec seems to be one of the few large areas in North America not serviced by helicopter. Helicopter crew composition varies from province to province across the country, and can have mixed paramedic support.
In all provinces, trauma centers have been established in larger cities. The beginning of regionalized trauma care in Canada was started by a small group of physicians and administrators working within separate provincial jurisdictions up to the early 1990s. After the establishment of a backbone of level one qualified centers, an equally small group of trained surgeons built the current programs. Much of the work was done with (in some cases) or in spite of provincial health care mandates. The struggle to update the trauma services has been done without definitive financial priority. Core expertise associations in surgery, orthopaedic surgery, and other subspecialties have collaborated across provincial borders to advance significantly the maturation of the trauma programs. The trauma surgeons came together in the Trauma Association of Canada (TAC) in 1983, and more recently, the Canadian Orthopaedic Trauma Society as a subsection of the Canadian Orthopedic Association has become a leader in this area.
TAC was initially conceived as a substructure of the Royal College (national medical accreditation body), as a surgical association committed to trauma care on a national scale despite there being no legislative mandate to accomplish a trauma program. Shortly afterward TAC was established as a subcommittee within the Canadian Association of General Surgeons. TAC had established guidelines for the organization and staffing of tertiary, district, and rural centers based on much of the same criteria as the American College of Surgeons. According to TAC, a trauma system in Canada was to be roughly based on a population of 1 to 2 million. There could be more than one tertiary trauma center and related trauma centers in a provincial or regional system. They were to be coordinated and governed by the Trauma Provincial Advisory Committee on Trauma Services for the province or region (e.g., beyond provincial boundaries).
Each province and region has a large variation in the delivery of care. Looking at results from the national database over a 6-year period, examining almost 79,000 trauma patients, 10% of these died in hospital mainly from injuries associated with head or chest wall injuries. Risk-adjusted mortality varied from 7.0% to 14.2% across provinces. Mortality decreased with increasing number of recommended trauma system elements. Provinces with more recommended trauma system components had better patient survival. This study did not include patients from Quebec which has no helicopter service. This is in part due to Quebec not participating in any national database programs, instead choosing to run their own databases that are not open to public or physician purview. One paper looking at the Quebec data did not find a difference from Canadian values but the prehospital death rate was not examined. Recently, the Canadian Institute for Health Information has stopped tracking trauma patients across the whole country. This makes it difficult to judge treatment policy efficacy.
Canada has 3 levels of trauma-center designation similar to ACS designations. The required professional disciplines for trauma care are set out in the accreditation guidelines. Most designated academic or regional trauma hospitals have a support team of a trauma medical director, trauma manager and team, as well as registry/data personnel and secretarial support. This team was to be responsible for organizing system care, including working with prehospital services on communication and triage, as well as coordinating multidisciplinary acute care and quality management.[10,11] Across the country, trauma-team leaders are appointed and usually funded in larger trauma centers. Team composition varies. Emergency physicians are present in the department in all large centers in Canada. In some trauma centers, these emergency physicians are fellowship trained in emergency medicine. Organization of the receiving trauma service will vary, across the country, with major-trauma volumes but usually include a TTL and a cohort of subspecialty support. Activation logistics depend on the individual hospitals. Activation thresholds are center specific, but these typically include standard American College of Surgeons Committee on Trauma Guidelines.
Critical care after initial response is typically provided in multidisciplinary medical/surgical units with primary responsibility by intensivists. These are surgeons, internists, or anesthetists with additional training in critical care. The many nuances of the trauma programs across the country became a bureaucratic burden for a subcommittee of the Canadian Association of General Surgeons. Management of approval and checking into compliance issues was too much for TAC to accomplish. Accreditation Canada (a not-for-profit organization partnering with patients, policy makers, and the public to improve the quality of health and social services) was brought in as a partner and the TAC standards were changed and have been positioned under the Trauma Distinction Program (https://accreditation.ca/files/trauma-info-package-en.pdf) with Accreditation Canada since 2014.
Accreditation adheres to the following determination of worthiness: the degree of compliance with the standards, the achievement of performance indicator thresholds, the implementation of trauma protocols or clinical practice guidelines, and commitment to excellence and innovation. The centers then have to be compliant with a long list of criteria in order to achieve accreditation. Post-acute care outside of the urgent care hospital designation is even more heterogeneous between provinces. Some provinces have no step down capability or rehabilitation hospitals while others have quite extensive systems. In the acute care setting most hospitals provide some degree of ambulatory rehabilitation services, but the nature of these services varies according to provincial plan.
The Canada Health Act does not cover many other services, including medically necessary services outside of hospitals, such as home care, rehabilitation services, and prescription drugs. Some help for trauma rehabilitation costs does come from alternate government funding envelopes such as workman's compensation or automobile insurance packages. Outpatient and ambulatory community rehabilitation services are not covered in universal care payments. Those with resources get more access to the system and a more predictable level of care. This is seen by some to be a more efficient use of resources and by others to be a weakness of the program! It certainly has fostered many debates at all levels of society.
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