- Email: [email protected]
A plea for Croatian trauma system
Injury, Int. J. Care Injured 44 S3 (2013) S3–S6
Contents lists available at SciVerse ScienceDirect
Injury j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i n j u r y
A plea for Croatian trauma system Tonisav Antoljaka,*, Ivan Dobrica, Bore Bakotab, Tomislav Zigmana, Daniel Rajacica, Tin Ehrenfreunda a
Department for Traumatology and Bone & Joint Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, Croatia Department for Surgery, General Hospital Karlovac, Karlovac, Croatia
b
KEYWORDS
ABSTRACT
Croatia trauma trauma care trauma system
This paper provides an insight into Croatian health system with special focus on trauma care. The current situation is explained from a domestic point of view, but an independent review by foreign observers is also included. Fragmented approach to the treatment of injured patients in Croatia should be replaced by networking of health care componenets into a unique chain of help. The concept and five methodological steps in the development of a succesfull trauma system are presented. A good start is definitely a reorganization of existing knowledge on the basis of internationally licesed courses and the adoption of trauma registry as a standard for future discussion. Individual components of the trauma system can not be separately “optimized” so clinical and financial decisions should be planned exclusively on the integral level. © 2013 Elsevier Ltd. All rights reserved.
Introduction In Croatia, 4.3 million citizens are unevenly distributed over 21 counties, with an average population density of 75.8 persons per km2. The rate of natural increase is negative and the population trend demonstrates aging. Measured by GDP per capita, Croatia is considerably behind the EU average. The unemployment rate is high, and economic indicators are currently negative. Consumer prices show a significant increase in health care and energy prices. More than a third of Croatian citizens are at risk of poverty and social exclusion. 35% of Croatian territory refers to the sea with 1244 islands, among them only 48 are permanently populated. During summer season, seaside is overcrowded with more than 11 million tourist which puts addiotional pressure to the organization of health care. During the past ten years, the third leading cause of death in Croatia was due to external causes of injury and poisoning (ICD-10 code: V00-V99, W00-W99, X00-X99, Y00-Y99).1 In 2010 standardized death rate (SDR) was 52/100,00 0 (EU average: 36/100,000).2 Top causes were falls (36%), suicide (26%) and traffic accidents (17%). Children and young people (0-39 years) mostly die due to road traffic accidents, middle-aged (40-64 years) due to suicide, and elderly (+65 years) due to falls.1 In 2010, SDR due to road traffic accidents in Croatia was 9.59 (EU average: 5.97).2 Basic health insurance is compulsory and carried out by state governed Croatian Institute for Health Insurance. Supplementary and private health insurance is voluntary. There are three levels * Corresponding author at: Department for Traumatology and Bone & Joint Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, Croatia E-mail address: [email protected] (T. Antoljak). 0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
of care. Primary health care is provided by general practitioners (i.e. family doctors), gynecologists, pediatricians (for infants and preschool children only), dentists, occupational medicine and pharmacists, mostly on the basis of concessions or in private practice. Health facilities at the secondary level are owned by counties. These include rehabilitation centers, clinics and small hospitals. Tertiary level comprises 11 university clinics, all but one owned by the state. More than one half of the university clinics are located in the capital city. Capital city has less than 20% of the total population in Croatia. Pre-hospital setting In Croatia, the term “emergency medical service” (EMS) is constrained exclusively to the provision of medical aid in prehospital setting, although emergency departments in hospitals also function. In this narrow term, EMS is considered as a part of primary health care owned by counties, even tough it is controlled and paid by the state insurance fund. There are four lines of treatment: - Fully equipped ambulance car with EMS physician, registered nurse and driver (Team 1) - Fully equipped ambulance car with two EMS nurses (Team 2) - General practitioners on call, mainly in rural areas. Official estimates suggest that 4/5 of population is covered by EMS, and the remaining 1/5 by general practitioners.1 - Immobile, but non acute patients are accompanied by EMS driver in an ambulance with basic equipment. This kind of health service is in the process of separation from EMS. Croatian counties differ significantly in total area and population density. For example, Zagreb has population 1,232
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T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6
people/km2 and Lic ˇko-senjska County only 10 people/km2. During 2010, one EMS team covered nearly 10,000 people and each of them had 2,687 interventions in average. The average medical transportation time was 49 minutes and 45 seconds. Under special conditions, army facilities can be activated for emergency medical air transportation and in 2011 there were 1,387 flights totally. Boat transfer is also available on inhabited islands, but the means of transportation are rather inappropriate.1 Couple of years ago, specialization in EMS for physicians was introduced in Croatia, but without a clear vision whether it should be pre-hospital or hospital based profession. Senior physicians, former GP’s, were promoted to the status of a specialist, but without any formal examination, and the younger ones started their residency mainly in hospitals. Hospital setting A total of 29 acute hospitals are participating in trauma network. Each of them carries the responsibility for a certain part of the country on equal basis though they vary considerably in human capacity and equipment. In other words, the accreditation process in Croatia has not started yet, although the government agency was established few years ago. Due to the lack of corresponding specialists, hospital emergency departments still functions in fragmented sections. All together, this causes a clear inequality of initial trauma care, depending on geographic location of injury. Review from abroad Thanks to MATRA funds, two projects were accomplished during 2008 and 2009 in cooperation between Croatian ministry of health on one side, and Dutch ministry of foreign affairs, Dutch ministry of health and Dutch Association of trauma centers on the other. These projects were: “Developing Croatian Trauma System through open communication” and “Empowering the professional through networks”. A high delegation of Dutch experts visited Croatia several times with objectives to gain insight into present trauma care in Croatia and to assist in the policy development of future Croatian trauma system. In a written report to Croatian government it was clearly stated that present level of trauma care in Croatia is not up to the standards of EU. It was strongly advised to the Croatian Ministry of Health to improve this situation and create equal access to trauma care throughout Croatia. Besides this core finding, few other problems were highlighted: - Heterogeneity in human resources, training and equipment - Absence of group goals, methods and priorities - Discoordination among health care segments, especially between pre-hospital and hospital setting - Unawareness of unique chain of help in trauma care - Lack of objective data (trauma registry) - Lack of leadership in decision-making From Croatian point of view, the following remarks from Dutch colleagues are worth mentioning: - Personal attitudes prevail instead of written protocols, guidelines and standard procedures - Discussions are dominated by individual opinions whose acceptance depends on the position of the debater in the hierarchy - Changes are hard to achieve because health care professionals do not tend to accept ideas from other professionals, institutions or trauma care segments. They call upon the government to take some action and use formal power to
-
overcome these shortcomings as if they are still functioning in the centralized system they once had. The government is taking initiatives, but until now not in a coordinated and concerted manner. It takes time for plans to be implemented and after that additional time is needed to check the programs in health care practice. Unfortunately, plans in Croatia are already changed or stopped before they become really effective because of changing political priorities or shortage in funding. Both the government and health care professionals are consequently frustrated.
Steps to be taken Trauma system is an organized, coordinated effort in a defined geographic area that delivers the full range of care to all injured patients, and which is integrated with the local public health system.3 According to the definition, key components of the system are: pre-hospital care, acute hospital care, rehabilitation and public health measures. Under circumstances of sharp division among these links, the main challenge is to connect all of them into a firm chain of help to injured people using communication and coordination activities as well as ongoing evaluation processes. Four premises are essential: 1. Saving life is of highest importance, not reducing disability 2. Injury is not a simple sum of individual diagnosis, but a complex condition/illness causing a reaction of the whole organism 3. Due to the complexity of injury, trauma patients require multidisciplinary treatment 4. Definitive treatment of injured people should be carried out not in the nearest, but in the nearest competent hospital. Following international experience,3–7 a trauma system should be developed using five steps: 1. Reorganization of existing knowledge of health care professionals 2. Development of standardized trauma units 3. Organization of trauma centers through intrahospital integration of health care capacities 4. Organization of trauma system through coordination of health system with other public services 5. Promulgation of trauma system as a factor adding to social stability. This is of particular importance in Europe, because injuries affect mostly less privileged people.8,9 Injuries are life threatening conditions which occur suddenly and unexpectedly. For this reason, their treatment should have the highest priority, above all other emergencies in medicine. Even more, treatment of injuries requires teamwork which implies demonstration of high quality of common knowledge under stress. Problem of postgraduate education has already been recognized in developing countries.10–14 In at least one of them, Trinidad, a regular institution of internationally licensed courses has been documented to lower the mortality rate of trauma victims.15–17 Without any doubt, health care staff in Croatia has a respectable amount of knowledge. However, this knowledge is accumulated in postgraduate period on an individual basis and according to personal preferences, and it is largely financed on own expense. Therefore, it is of uneven quality and very often fragmented. In Croatia, a key component of improvements in trauma care should be optimising training using internationally licensed courses. This provides the following priorities:
T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6
1. Determining the minimum of common knowledge in trauma care 2. Establishing clear priorities in treatment of injured persons 3. Installation of evidence based medicine (EBM) as the only correct way in treatment of acutely injured people 4. Teamwork training 5. Licensing and relicensing of health care staff based on professional standards rather than on academic knowledge. Regarding this issue, the situation in Croatia is currently not encouraging. Surgical Society, the principal professional association, is not interested to introduce ATLS because of high initial costs. Croatian Resuscitation Council has recently started with ETC, but the courses are rare and expensive for an individual. Starting from 2004, over 2000 doctors and nurses completed ITLS training and the course has been well received. On the other hand, ITLS is designed for pre-hospital setting, not for hospitals, so it can not be the only part of the didactic core of the future Croatian trauma system. Finally, Croatian Institute of Emergency Medicine started in 2011 with some kind of education sponsored by World bank. Since this effort is designed according to personal preferences of the leaders, it does not address the need for standardized education based on EBM. Next to reorganization of knowledge based on internationally licensed courses, a good start for the Croatian trauma system would be data collecting in a single trauma registry. When presenting the analysis, in should be born in mind that adverse outcomes are not always a reflection of poor medical care. The imprefection of the system causes the majority of mistakes, rather than the individual.18 The second step in the development of the trauma system is the organization of the trauma unit (TU). This is not an observation room, not an operation theatre for elective surgery and there are no regular patients. Spatially it can be an integral part of the emergency department (ED) or separately organized entity.7 Whichever option is chosen, trauma unit must be the only admitting area in the hospital for the treatment of acutely injured people. Due to the ongoing emergency procedures, key criteria for construction and equipment should be efficiency, affordability, simplicity and visibility. Procurement and arrangement of equipment is the easy part, but the real challenge is building trauma teams7. Trauma team is a multidisciplinary, trained and organized group of health care professionals who take the full responsibility for emergency trauma patients.19 This goes well beyond the usual procedures such as diagnosis and initial stabilization of vital parameters.20 Important features of teamwork are: dedication and commitment, complementary skills, mutual trust and timely fulfillment of agreed tasks. Completing ATLS or ETC is a prerequisite for teamwork in the trauma unit. Some of the responsibilities of a team leader are: data collection from pre-hospital service, setting priorities in the diagnosis and treatment, the interpretation of patient data, coordination of intra- and inter-hospital transfer, communication with consultants and primary triage during disaster management.20 Although an anesthesiologist, general surgeon or EM specialist can be nominated as a team leader, for Croatian circumstances we strongly advocate trauma surgeons. During war in Croatia 1991-1995 they have proven their value and we do not support recent merging of trauma surgery with orthopedics as suggested from EU. Having a well-equipped, well-operating trauma unit does not make a shift from regular hospital to a trauma center.7 Actually, trauma centers are verified acute hospitals where emergency trauma patients have the priority over all other patients. Intrahospital integration of all necessary medical specialties needs to
S5
be implemented in practice as they provide complete, coordinated and efficient care to all injured people 24h/7 days. Besides, trauma center should have developed systems for education, injury surveillance, data collection and quality improvement.21,22 Good communication and cooperative relationships should be maintained with other hospitals in region as well as transportand by pass-agreements.21,22 Coordination with other public services is also required. These standards are hardly to achieve without a lots of commitment from hospital administration.7 Most important point is that there is no need to build new, special hospitals for trauma centers. All that is needed is to reorganize the existing capacities upon new principles. Almost 14 years ago EU has announced a network of trauma centers along major transport corridors to maximize the safety of passengers. Each of these trauma centers should cover a population up to one million people.23 A trauma center does not make a trauma system7. Main feature of a good trauma system is to link prehospital, hospital, rehabilitation and public-health efforts in a solid, uninterrupted chain of trauma care. In Croatia, pre-hospital EMS transports patients to the nearest hospital. As well known, this can significantly decrease the transport time in large, densely populated cities but might have negative implications for in-hospital mortality, as centers without adequate resources might be receiving patients for which they are unprepared.24 On the other hand. the general principle of a good trauma system in pre-hospital setting is to identify and manage any life-threatening injuries, and then to transport the patient to an appropriate facility as soon as possible to receive definitive treatment.25–28 Any delay in the transport time or delay in the ongoing treatment of life-threatening injuries may jeopardize the common goal: saving as many lives as possible. Therefore, we do not advocate “Stay & Play” or “Scoop & Run” phylosophy in pre-hospital trauma care, but “Run & Play”. We believe that ITLS in Croatia provides sufficient basis for the achievment of this standard, so we strongly recommend this course as a mandatory part of education of pre-hospital personnel in Croatia, both doctors and nurses. Although without EBM support on this issue, there seems to be a trend in EU towards integration of pre-hospital teams in hospital ED’s in order to increase the quality of trama care in the field and to reduce costs.29,30 If this is true, then the nurses should take over considerable responsibility in pre-hospital setting. This process has already been started in Croatia through activities of Croatian Institute of Emergency medicine (Team 2). As monitoring parameters are not well defined, the future of this project will depend again on the political will of the goverment. For now, the introduction of paramedics in trauma care in Croatia is not an option. Particularly in the case of road traffic accidents, there is no doubt that lay bystanders can play a crucial role.23 Besides some actions like rapid extrication from a burning vehicle or establishing a contact with emergency services, lay bystanders need to be able to secure a free airway in unconsious victim and to treat immediately major bleeding. This is particularly important to reduce preventable deaths. The presence of gloves in the car to protect the bystander during these actions is desirable. Even more, there is no evidence to suggest that first aid kits being made available in cars would help. In this sense, we suggest a shift from the current targets of teaching of first aid for drivers towards more modern knowledge. Basic ITLS would be a good choice. The need for transportation of injured persons to the nearest competent hospital has been emphasized several times. In other words, some hospitals in Croatia will be passed by in the future trauma network due to lack of human resources or
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equippment. They will lose some of their importance, and probably part of their income, while some other hospitals will be increasingly burdened so they will ask for more money. We agree that accreditation is an extremely delicate process with a lot of political implications, but it has to be done. Because of the potential impact on the survival and invalidity of trauma patients, action between professional organizations and the government must be coordinated and presented to the public on the basis of clear and agreed information. Finally, each trauma system has to be tailored to fit local circumstances, but the program is effective only when it involves the whole chain of help in trauma care, not just individual links. Therefore, option advocated by Croatian Institute of Emergency medicine is not satisfactory, because it relies just on improvement of pre-hospital services. Mere question remains what will be the trigger point that will bring together the government, professional health care associations and citizens in order to build a new organizational structure on the principles of cooperation and goodwill as well as with respect to knowledge and experience from abroad. Conflict of interest All authors declare they have no conflicts of interest. References 1. 2. 3. 4. 5. 6. 7. 8. 9.
National Health Development Stategy 2011-2020, Sept. 2012. European health for all database, WHO Regional Office for Europe, Copenhagen, Denmark, July 2012. American Trauma Society: Trauma System-Agenda for the Future. 2002. United Nations, General Assembly, 1 August 2003: Global Road Safety Crisis. Report of the Secretary-General. Advanced trauma life support for doctors. Instructor course manual, 6th ed., American College of Surgeons, Chicago; 1997. SMARTRISK, Health Canada, Emergency Health Services Branch Ministry of Health: The Economic Burden of Unintentional Injury in Canada; 1998. Michaelson M. Building a Trauma System-The Rambam Medical Center Experience. Trauma Care 12(2), Fall 2002. La Flamme L. Social Inequality in Injury Risks. Knowledge Accumulated and Plans for the Future. Sweden, Karolinska Institutet, 1998. La Flamme L. Explaining socio-economic differences in injury risk. Injury Control and Safety Promotion 2001;8(3):149-153.
10. Civil IDS. Trauma care - a team sport in the 21st century. Injury, Int. J. Care Injured 2007;38:5—6. 11. Mock CN, Quansah R, Addae-Mensah L, DonkorP. The development of continuing education for trauma care in an African nation. Injury, Int. J. Care Injured 2005;36:725—732. 12. Dai K, Xu Z, Zhu L. Trauma care systems in China. Injury, Int. J. Care Injured 2003;34:664–8. 13. Civil IDS. Good trauma care doesn’t happen by accident. Injury, Int. J. Care Injured 2005;36:689—690. 14. WHO: Prehospital Trauma Care Systems, Geneva 2005. 15. Ali J, Adams R, Butler AK, et al. Trauma outcome improves following the advanced trauma life support program in a developing country. J Trauma 1993;34:890—8. 16. Ali J, Adams R, Stedman M, et al. Advanced trauma life support program increases emergency room application of trauma resuscitative procedures. J Trauma 1994;36:391—4. 17. Ali J, Adam RU, Gana TJ, Williams JI. Trauma patient outcome after the Prehospital Trauma Life Support program. J Trauma 1997;42(6):1018-21. 18. Performance Improvement Subcommitteeof the American College of Surgeons Committee on Trauma. Trauma performance improvement. Reference Manual. Jan 2002. 19. State of California, Emergency Medical Services Authority. Chapter 7. Trauma Care Systems, California, 2003. 20. Driscoll PA, Vincent CA. Organizing an efficient trauma team. Injury 1992;23:107–110. 21. West JG, Williams MJ, Trunkey DD, Wolferth CC Jr. Trauma systems: current status — future challenges. JAMA 1988;259(24):3597-600. 22. Kortebeek JB. A review of trauma systems using the Calgary model. Can J Surg 2000;43:23-8. 23. European Transport Safety Council. Reducing the Severity of Road Injuries Through Post Impact Care, Brussels 1999. 24. Roudsari BS, Nathens AB, Arreola-Risa C, Cameron P, Civil I, Grigoriou G et al. Emergency Medical Service (EMS) systems in developed and developing countries. Injury, Int. J. Care Injured 2007;38:1001—13. 25. Coats TJ, Goode A. Towards improving prehospital trauma care. Lancet 2001;357:2070 26. Kristiansen T, Søreide K, Ringdal KG, Rehn M, Krüger AJ, Reote A et al. Trauma systems and early management of severe injuries in Scandinavia: review of the current state. Injury 2010;41:444–52. 27. Mackersie RC. History of trauma field triage development and the American College of Surgeons criteria. Prehosp Emerg Care 2006;10:287–94. 28. Sharma BR. Development of pre-hospital trauma-care system—an overview. Injury 2005;36:579–87. 29. Council of the European Society for Emergency Medicine. Manifesto for Emergency Medicine in Europe. European Journal of Emergency Medicine 1998;1:7-8. 30. Council of the European Society for Emergency Medicine: Manifesto for Emergency Medicine in Europe, revision. European Journal of Emergency Medicine 1998;5(4):1-2.
Contents lists available at SciVerse ScienceDirect
Injury j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i n j u r y
A plea for Croatian trauma system Tonisav Antoljaka,*, Ivan Dobrica, Bore Bakotab, Tomislav Zigmana, Daniel Rajacica, Tin Ehrenfreunda a
Department for Traumatology and Bone & Joint Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, Croatia Department for Surgery, General Hospital Karlovac, Karlovac, Croatia
b
KEYWORDS
ABSTRACT
Croatia trauma trauma care trauma system
This paper provides an insight into Croatian health system with special focus on trauma care. The current situation is explained from a domestic point of view, but an independent review by foreign observers is also included. Fragmented approach to the treatment of injured patients in Croatia should be replaced by networking of health care componenets into a unique chain of help. The concept and five methodological steps in the development of a succesfull trauma system are presented. A good start is definitely a reorganization of existing knowledge on the basis of internationally licesed courses and the adoption of trauma registry as a standard for future discussion. Individual components of the trauma system can not be separately “optimized” so clinical and financial decisions should be planned exclusively on the integral level. © 2013 Elsevier Ltd. All rights reserved.
Introduction In Croatia, 4.3 million citizens are unevenly distributed over 21 counties, with an average population density of 75.8 persons per km2. The rate of natural increase is negative and the population trend demonstrates aging. Measured by GDP per capita, Croatia is considerably behind the EU average. The unemployment rate is high, and economic indicators are currently negative. Consumer prices show a significant increase in health care and energy prices. More than a third of Croatian citizens are at risk of poverty and social exclusion. 35% of Croatian territory refers to the sea with 1244 islands, among them only 48 are permanently populated. During summer season, seaside is overcrowded with more than 11 million tourist which puts addiotional pressure to the organization of health care. During the past ten years, the third leading cause of death in Croatia was due to external causes of injury and poisoning (ICD-10 code: V00-V99, W00-W99, X00-X99, Y00-Y99).1 In 2010 standardized death rate (SDR) was 52/100,00 0 (EU average: 36/100,000).2 Top causes were falls (36%), suicide (26%) and traffic accidents (17%). Children and young people (0-39 years) mostly die due to road traffic accidents, middle-aged (40-64 years) due to suicide, and elderly (+65 years) due to falls.1 In 2010, SDR due to road traffic accidents in Croatia was 9.59 (EU average: 5.97).2 Basic health insurance is compulsory and carried out by state governed Croatian Institute for Health Insurance. Supplementary and private health insurance is voluntary. There are three levels * Corresponding author at: Department for Traumatology and Bone & Joint Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, Croatia E-mail address: [email protected] (T. Antoljak). 0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
of care. Primary health care is provided by general practitioners (i.e. family doctors), gynecologists, pediatricians (for infants and preschool children only), dentists, occupational medicine and pharmacists, mostly on the basis of concessions or in private practice. Health facilities at the secondary level are owned by counties. These include rehabilitation centers, clinics and small hospitals. Tertiary level comprises 11 university clinics, all but one owned by the state. More than one half of the university clinics are located in the capital city. Capital city has less than 20% of the total population in Croatia. Pre-hospital setting In Croatia, the term “emergency medical service” (EMS) is constrained exclusively to the provision of medical aid in prehospital setting, although emergency departments in hospitals also function. In this narrow term, EMS is considered as a part of primary health care owned by counties, even tough it is controlled and paid by the state insurance fund. There are four lines of treatment: - Fully equipped ambulance car with EMS physician, registered nurse and driver (Team 1) - Fully equipped ambulance car with two EMS nurses (Team 2) - General practitioners on call, mainly in rural areas. Official estimates suggest that 4/5 of population is covered by EMS, and the remaining 1/5 by general practitioners.1 - Immobile, but non acute patients are accompanied by EMS driver in an ambulance with basic equipment. This kind of health service is in the process of separation from EMS. Croatian counties differ significantly in total area and population density. For example, Zagreb has population 1,232
S4
T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6
people/km2 and Lic ˇko-senjska County only 10 people/km2. During 2010, one EMS team covered nearly 10,000 people and each of them had 2,687 interventions in average. The average medical transportation time was 49 minutes and 45 seconds. Under special conditions, army facilities can be activated for emergency medical air transportation and in 2011 there were 1,387 flights totally. Boat transfer is also available on inhabited islands, but the means of transportation are rather inappropriate.1 Couple of years ago, specialization in EMS for physicians was introduced in Croatia, but without a clear vision whether it should be pre-hospital or hospital based profession. Senior physicians, former GP’s, were promoted to the status of a specialist, but without any formal examination, and the younger ones started their residency mainly in hospitals. Hospital setting A total of 29 acute hospitals are participating in trauma network. Each of them carries the responsibility for a certain part of the country on equal basis though they vary considerably in human capacity and equipment. In other words, the accreditation process in Croatia has not started yet, although the government agency was established few years ago. Due to the lack of corresponding specialists, hospital emergency departments still functions in fragmented sections. All together, this causes a clear inequality of initial trauma care, depending on geographic location of injury. Review from abroad Thanks to MATRA funds, two projects were accomplished during 2008 and 2009 in cooperation between Croatian ministry of health on one side, and Dutch ministry of foreign affairs, Dutch ministry of health and Dutch Association of trauma centers on the other. These projects were: “Developing Croatian Trauma System through open communication” and “Empowering the professional through networks”. A high delegation of Dutch experts visited Croatia several times with objectives to gain insight into present trauma care in Croatia and to assist in the policy development of future Croatian trauma system. In a written report to Croatian government it was clearly stated that present level of trauma care in Croatia is not up to the standards of EU. It was strongly advised to the Croatian Ministry of Health to improve this situation and create equal access to trauma care throughout Croatia. Besides this core finding, few other problems were highlighted: - Heterogeneity in human resources, training and equipment - Absence of group goals, methods and priorities - Discoordination among health care segments, especially between pre-hospital and hospital setting - Unawareness of unique chain of help in trauma care - Lack of objective data (trauma registry) - Lack of leadership in decision-making From Croatian point of view, the following remarks from Dutch colleagues are worth mentioning: - Personal attitudes prevail instead of written protocols, guidelines and standard procedures - Discussions are dominated by individual opinions whose acceptance depends on the position of the debater in the hierarchy - Changes are hard to achieve because health care professionals do not tend to accept ideas from other professionals, institutions or trauma care segments. They call upon the government to take some action and use formal power to
-
overcome these shortcomings as if they are still functioning in the centralized system they once had. The government is taking initiatives, but until now not in a coordinated and concerted manner. It takes time for plans to be implemented and after that additional time is needed to check the programs in health care practice. Unfortunately, plans in Croatia are already changed or stopped before they become really effective because of changing political priorities or shortage in funding. Both the government and health care professionals are consequently frustrated.
Steps to be taken Trauma system is an organized, coordinated effort in a defined geographic area that delivers the full range of care to all injured patients, and which is integrated with the local public health system.3 According to the definition, key components of the system are: pre-hospital care, acute hospital care, rehabilitation and public health measures. Under circumstances of sharp division among these links, the main challenge is to connect all of them into a firm chain of help to injured people using communication and coordination activities as well as ongoing evaluation processes. Four premises are essential: 1. Saving life is of highest importance, not reducing disability 2. Injury is not a simple sum of individual diagnosis, but a complex condition/illness causing a reaction of the whole organism 3. Due to the complexity of injury, trauma patients require multidisciplinary treatment 4. Definitive treatment of injured people should be carried out not in the nearest, but in the nearest competent hospital. Following international experience,3–7 a trauma system should be developed using five steps: 1. Reorganization of existing knowledge of health care professionals 2. Development of standardized trauma units 3. Organization of trauma centers through intrahospital integration of health care capacities 4. Organization of trauma system through coordination of health system with other public services 5. Promulgation of trauma system as a factor adding to social stability. This is of particular importance in Europe, because injuries affect mostly less privileged people.8,9 Injuries are life threatening conditions which occur suddenly and unexpectedly. For this reason, their treatment should have the highest priority, above all other emergencies in medicine. Even more, treatment of injuries requires teamwork which implies demonstration of high quality of common knowledge under stress. Problem of postgraduate education has already been recognized in developing countries.10–14 In at least one of them, Trinidad, a regular institution of internationally licensed courses has been documented to lower the mortality rate of trauma victims.15–17 Without any doubt, health care staff in Croatia has a respectable amount of knowledge. However, this knowledge is accumulated in postgraduate period on an individual basis and according to personal preferences, and it is largely financed on own expense. Therefore, it is of uneven quality and very often fragmented. In Croatia, a key component of improvements in trauma care should be optimising training using internationally licensed courses. This provides the following priorities:
T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6
1. Determining the minimum of common knowledge in trauma care 2. Establishing clear priorities in treatment of injured persons 3. Installation of evidence based medicine (EBM) as the only correct way in treatment of acutely injured people 4. Teamwork training 5. Licensing and relicensing of health care staff based on professional standards rather than on academic knowledge. Regarding this issue, the situation in Croatia is currently not encouraging. Surgical Society, the principal professional association, is not interested to introduce ATLS because of high initial costs. Croatian Resuscitation Council has recently started with ETC, but the courses are rare and expensive for an individual. Starting from 2004, over 2000 doctors and nurses completed ITLS training and the course has been well received. On the other hand, ITLS is designed for pre-hospital setting, not for hospitals, so it can not be the only part of the didactic core of the future Croatian trauma system. Finally, Croatian Institute of Emergency Medicine started in 2011 with some kind of education sponsored by World bank. Since this effort is designed according to personal preferences of the leaders, it does not address the need for standardized education based on EBM. Next to reorganization of knowledge based on internationally licensed courses, a good start for the Croatian trauma system would be data collecting in a single trauma registry. When presenting the analysis, in should be born in mind that adverse outcomes are not always a reflection of poor medical care. The imprefection of the system causes the majority of mistakes, rather than the individual.18 The second step in the development of the trauma system is the organization of the trauma unit (TU). This is not an observation room, not an operation theatre for elective surgery and there are no regular patients. Spatially it can be an integral part of the emergency department (ED) or separately organized entity.7 Whichever option is chosen, trauma unit must be the only admitting area in the hospital for the treatment of acutely injured people. Due to the ongoing emergency procedures, key criteria for construction and equipment should be efficiency, affordability, simplicity and visibility. Procurement and arrangement of equipment is the easy part, but the real challenge is building trauma teams7. Trauma team is a multidisciplinary, trained and organized group of health care professionals who take the full responsibility for emergency trauma patients.19 This goes well beyond the usual procedures such as diagnosis and initial stabilization of vital parameters.20 Important features of teamwork are: dedication and commitment, complementary skills, mutual trust and timely fulfillment of agreed tasks. Completing ATLS or ETC is a prerequisite for teamwork in the trauma unit. Some of the responsibilities of a team leader are: data collection from pre-hospital service, setting priorities in the diagnosis and treatment, the interpretation of patient data, coordination of intra- and inter-hospital transfer, communication with consultants and primary triage during disaster management.20 Although an anesthesiologist, general surgeon or EM specialist can be nominated as a team leader, for Croatian circumstances we strongly advocate trauma surgeons. During war in Croatia 1991-1995 they have proven their value and we do not support recent merging of trauma surgery with orthopedics as suggested from EU. Having a well-equipped, well-operating trauma unit does not make a shift from regular hospital to a trauma center.7 Actually, trauma centers are verified acute hospitals where emergency trauma patients have the priority over all other patients. Intrahospital integration of all necessary medical specialties needs to
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be implemented in practice as they provide complete, coordinated and efficient care to all injured people 24h/7 days. Besides, trauma center should have developed systems for education, injury surveillance, data collection and quality improvement.21,22 Good communication and cooperative relationships should be maintained with other hospitals in region as well as transportand by pass-agreements.21,22 Coordination with other public services is also required. These standards are hardly to achieve without a lots of commitment from hospital administration.7 Most important point is that there is no need to build new, special hospitals for trauma centers. All that is needed is to reorganize the existing capacities upon new principles. Almost 14 years ago EU has announced a network of trauma centers along major transport corridors to maximize the safety of passengers. Each of these trauma centers should cover a population up to one million people.23 A trauma center does not make a trauma system7. Main feature of a good trauma system is to link prehospital, hospital, rehabilitation and public-health efforts in a solid, uninterrupted chain of trauma care. In Croatia, pre-hospital EMS transports patients to the nearest hospital. As well known, this can significantly decrease the transport time in large, densely populated cities but might have negative implications for in-hospital mortality, as centers without adequate resources might be receiving patients for which they are unprepared.24 On the other hand. the general principle of a good trauma system in pre-hospital setting is to identify and manage any life-threatening injuries, and then to transport the patient to an appropriate facility as soon as possible to receive definitive treatment.25–28 Any delay in the transport time or delay in the ongoing treatment of life-threatening injuries may jeopardize the common goal: saving as many lives as possible. Therefore, we do not advocate “Stay & Play” or “Scoop & Run” phylosophy in pre-hospital trauma care, but “Run & Play”. We believe that ITLS in Croatia provides sufficient basis for the achievment of this standard, so we strongly recommend this course as a mandatory part of education of pre-hospital personnel in Croatia, both doctors and nurses. Although without EBM support on this issue, there seems to be a trend in EU towards integration of pre-hospital teams in hospital ED’s in order to increase the quality of trama care in the field and to reduce costs.29,30 If this is true, then the nurses should take over considerable responsibility in pre-hospital setting. This process has already been started in Croatia through activities of Croatian Institute of Emergency medicine (Team 2). As monitoring parameters are not well defined, the future of this project will depend again on the political will of the goverment. For now, the introduction of paramedics in trauma care in Croatia is not an option. Particularly in the case of road traffic accidents, there is no doubt that lay bystanders can play a crucial role.23 Besides some actions like rapid extrication from a burning vehicle or establishing a contact with emergency services, lay bystanders need to be able to secure a free airway in unconsious victim and to treat immediately major bleeding. This is particularly important to reduce preventable deaths. The presence of gloves in the car to protect the bystander during these actions is desirable. Even more, there is no evidence to suggest that first aid kits being made available in cars would help. In this sense, we suggest a shift from the current targets of teaching of first aid for drivers towards more modern knowledge. Basic ITLS would be a good choice. The need for transportation of injured persons to the nearest competent hospital has been emphasized several times. In other words, some hospitals in Croatia will be passed by in the future trauma network due to lack of human resources or
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equippment. They will lose some of their importance, and probably part of their income, while some other hospitals will be increasingly burdened so they will ask for more money. We agree that accreditation is an extremely delicate process with a lot of political implications, but it has to be done. Because of the potential impact on the survival and invalidity of trauma patients, action between professional organizations and the government must be coordinated and presented to the public on the basis of clear and agreed information. Finally, each trauma system has to be tailored to fit local circumstances, but the program is effective only when it involves the whole chain of help in trauma care, not just individual links. Therefore, option advocated by Croatian Institute of Emergency medicine is not satisfactory, because it relies just on improvement of pre-hospital services. Mere question remains what will be the trigger point that will bring together the government, professional health care associations and citizens in order to build a new organizational structure on the principles of cooperation and goodwill as well as with respect to knowledge and experience from abroad. Conflict of interest All authors declare they have no conflicts of interest. References 1. 2. 3. 4. 5. 6. 7. 8. 9.
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