Structure and process components of trauma care services in Israeli acute-care hospitals

0 1998 Published

It~pry Vol. 29, No. 1, pp. 43-46, 1998 by Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020-1383198 $19.00 + 0.00

ELSEVIER

PII: SOO20-1383(97)00157-5

Structure and process services

in Israeli

R. Ben Abraham,‘,* and M. Stein’,”

components of trauma acute-care hospitals

R. J. Heruti,1,2,3 Y. Abramovitch,’

B. Marganit,‘,’

care

J. ShemeP

‘Israel Defense Force, Medical Corps, Israel, “Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel and ‘Neurologic Rehabilitation Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel It was only recently that the American system for dividing hospitals into three trauma centre categories (levels I, II, III), was adopted by the Israeli Ministry of Health based on the American College of Surgeons (ACS) mark%‘. A total of 24 hospitals, defined by the Ministry of Health as capable of receiving trauma patientsh, serve a population of 5.3 million scattered over an area of 21946 km’ (according to 1996 data). Six were defined as level I trauma centres, able to admit patients with multiple traumP. An organized trauma system incorporating all EMS is not yet available in Israel. A nationwide survey of ED in Israeli hospitals was conducted to: (1) describe structure and process components of trauma care services in ED in Israel; and (2) identify deficiencies in organization, personnel and equipment, required to provide optimal trauma care. It is hoped that data from this study will assist in the process of development of an organized national trauma care system in Israel. The results may also serve for comparison between EMS in different countries. Injury, Vol. 29, No. 1, 43-46, 1998

Introduction The outcome of the multiple-injury patient depends on the quality of initial treatment offered by the medical team in the field, as well as in the emergency department (ED). Optimal care of the seriously injured patient is reliant on the quality of the available emergency medical service (EMS)‘. Rapid response of the EMS in the pre-hospital phase and prompt evacuation to a proper medical centre capable of providing definitive care, are crucial to patient survival’,‘. Diagnostic measures and lifesaving procedures immediately applied to the injured can reduce morbidity and mortality’. Close co-operation between the EMS, the trauma team and other departments that provide support for the trauma patient is essentials.

Materials

and methods

Study design In February 1996, questionnaires were sent to medical directors of ED in all Israeli hospitals, defined by the Israeli Ministry of Health as capable of receiving trauma patient$. A total of 24 hospitals were so defined. Several small hospitals in the private sector were not included in the survey. Follow-up phone calls were used to itensify co-operation. Survey design A simple, 2%item questionnaire, using closed and open-ended questions, was developed. Respondents were asked to provide information concerning the organization, personnel and equipment available for treatment of the acutely-injured patient. Specific information was requested concerning the seniority

44

Injury:

International

and training of physicians on call for emergencies and the availability of imaging equipment in the ED. Questions were formulated based upon the criteria of the ACS for classification of hospitals involved in acute trauma care7. Results are expressed as mean f standard deviation.

Results A total of 24 hospitals were surveyed during a 4-month period. All responses were complete and received within that time. Respondents comprised 22 physicians (two deputy hospital administrators, 15 directors or chairs of ED and five directors of trauma units) and two trauma nurse co-ordinators. Structure and organization Data on the organization of EDs are presented in Table I. Specially-designed trauma units exist in all six tertiary-referral hospitals (level I), but only in three community hospitals (16.6 per cent). Eight of these units had a medical trauma director (general surgeons in seven, and an orthopaedist in one). Seventy-two resuscitation beds (trauma and medical) were available, with an average per hospital of 3.0+1.9. Resuscitation beds in the community and tertiary-referral hospitals averaged 2.4 T 1.1 and 5 f 2.5, respectively. The average number of regular beds (trauma and medical) per ED was 24 +lO (community, 22.1 k 10; tertiary centre, 30.6k7.0). A total of 19 hospitals (79.1 per cent) were found to have an ED with > 15 beds. Independent paediatric and gynaecology, ophthalmology and otolaryngology and orthopaedic ED exist in 20 (83 per cent), 16 (67 per cent) and 14 (58 per cent) of the hospitals, respectively (Table 1). Although these sub-speciality ED are available for the treatment of isolated injuries in most hospitals, all potentially lifemultiple-injury patients with threatening injuries are treated in the main ED of all the hospitals surveyed. Imaging equipment Table II depicts data on imaging equipment availability in the ED. Eight ED (five in tertiary-referral hospitals) were found to have specially-designed X-ray rooms with technicians constantly available. In

Journal

of the Care of the Injured

Vol. 29, No. 1,1998

all the others, a portable X-ray machine was found to be immediately available. However, in only 20 hospitals could an X-ray be performed within 5 min. Emergency ultrasound services for trauma evaluation were found to be available in every ED 24 h per day, but only 14 hospit& (45.5 per cent) had ultrasound services available 10 min. within Emergency computed tomography (CT) scans are alrailable in 22 (91.6 per cent) hospitals (all tertiary-referral). Thirteen hospitals had CT ‘scans available within 10 min. Emergency angiography was available in 17 (70.8 per cent) ED. Magnetic resonance imaging (MRI) scans are available in four (16.6 per cent) hospitals and spiral CT scans in 10 (41.6 per cent) hospitals. None of the hospitals can provide 24-h immediate availability of the MRI and spiral CT scanners. Personnel In 23 hospitals (96 per cent), residents in surgery are responsible for the initial care of the injured during night shifts, whilst in one hospital, a general practitioner or internist is responsible for the care of trauma patients. An Israeli, board-certified surgeon is present at night in only four hospitals (16 per cent). The level of training of the on-call surgeon varied in the remaining hospitals. Communication and equipment Although telephone communication is available between all hospital units concerned with trauma care (i.e. imaging department, blood bank, operating room), none of the hospitals have a complete intercom network linking all the units. All the hospitals provide monitored intra- and inter-hospital transport services. A mobile respirator with oxygen supply for patient transportation is available in all hospitals. An immediate supply of O-negative blood is present in only one ED. The rest rely on supply from the blood bank following specific request. Manpower In 17 hospitals (11 - community, six - tertiary referral) a regulation concerning the basic approach to primary trauma care was found. A trauma team, constantly on call for emergency trauma cases, is defined in only 13 hospitals (54 per cent), (8 community, five - tertiary referral). Ambulance

Table I. Structure and organization of EDs in Israel Community hospitals (n = 18) Number Number Number Number Separated Separated Separated Separated Separated

of of of of

designated trauma units in ED (per cent) resuscitation beds per hospital regular beds per hospital EDs with > 30 beds (per cent) paediatric ED (per cent) gynaecology ED (per cent) ophthalmology ED (per cent) orthopaedic ED (per cent) otolaryngology ED (per cent)

3 (16.6) 2.4il.l

22.1 f 10 0 14 (77.7) 16 (88.8) 12 (66.6) 11 (61.1) 12 (66.6)

Tertiary referral hospitals (level (n = 6)

I)

Total (n = 24)

6 (100)

9 (37.5)

5k2.5 30.6k7.0 6 (100) 6 (100) 4 (66.6) 4 (66.6) 3 (50) 4 (66.6)

3.0+ 1.9 24klO

6 (25) 20 20 16 14 16

(83.3) (83.3) (66.6) (58.3) (66.6)

Ben Abraham

et al.: Trauma

45

care services in Israel

Table II. Imaging equipment in EDs in Israel

Community hospitals (n = 18) Ultrasound (per cent) CT scan (per cent) Angiography (per cent) MRI (per cent) Spiral CT scan (per cent)

18 16 13 0 5

(100) (88.8) (54) (27.7)

Tertiary referral hospitals (/eve/ I) (n = 6) 6 6 4 4 5

(100) (100) (66.6) (66.6) (83.3)

Total (n = 24) 24 22 17 4 10

(100) (91.7) (70.8) (16.7) (41.7)

communication with the ED occurs in 275 per cent of trauma cases in 16 hospitals (66.6 per cent; 11 community, five - tertiary referral). A special system dedicated to trauma registry is available in only eight hospitals (29 per cent; two - community, six - tertiary referral). A special system dedicated to trauma registry is available in only eight hospitals (29 per cent; two - community, six - tertiary referral). In only five hospitals (20.8 per cent; four community, one - tertiary referral) is an intensive care unit (ICU) facility for the severely injured always available. The paediatric ICU always has a bed available in only 11 hospitals (45.8 per cent). A place for the injured in the burn or neurosurgery unit could always be found in ‘41.6 per cent of surveyed hospitals.

Discussion Trauma remains a major cause of morbidity and mortality. For many years, the consensus among members of the Israeli Medical Association was that the level of primary trauma care is satisfactory. A decade ago, several reports questioned adequacy of care for the injured in Israel’,“, and as a result, in recent years an effort was made to improve emergency trauma care services”‘. In order to improve cognitive knowledge and manual skills of those engaged in treatment of trauma, the Advanced Trauma Life Support (ATLS)” course program was initiated”. This initiative was only a part of a continuous effort to establish a co-ordinated emergency medical system in Israel. Twenty-four general hospitals exist in Israel, however, no formal classification (similar to that of the USA) into level I, II and Ill trauma centres exists;,lL.“. Six central medical, tertiary-referral centres were defined as such by the Ministry of Health for multiple-injured patients who need special intervention. Special equipment or surgical sub-speciality availability is mandatory only in these hospitals”. The EMS in Israel utilizes the defined tertiary trauma centres as their main targets for evacuation of the multiple-injury patient. Awareness of the importance of evacuating the injured to a hospital capable of providing adequate care has improved among Israeli EMS teams in recent years. This is, in part, a positive contribution of the ATLS” course content which was dispersed

among those responsible for primary care of the injured in Israel. Today, all tertiary-referral centres have dedicated trauma unit facilities within the ED. However, only 16.6 per cent of the community hospitals have dedicated trauma facilities. In the hospitals lacking trauma facilities, resuscitation beds are usually located in the surgical section of the ED. Nevertheless, in eight hospitals trauma patients are treated in the medical section of the emergency room. Although special trauma units may reduce the flexibility of allocation of nursing resources, modern trauma care is best provided in separate designated trauma units because of the unique equipment, personnel skills and space requirements for these patients. The organization of the ED and the immediate availability of experienced personnel and appropriate technical resources have a significant effect on the speed, efficiency and outcome of trauma care’. The results of this study indicate that there is a wide variation in the level of training and experience of the on-call trauma surgeons among the various hospitals surveyed. There is also a significant variation in the administrative commitment to the trauma patient. Only 54 per cent of the hospitals have a dedicated on-call trauma team capable of immediate response to a life-threatening injury. The quality of the primary trauma team is crucial for successful treatment’,‘. The existence of a well-organized team headed by a well-trained surgeon can contribute significantly to patient outcome, especially for those who are severely injured”. However, traumatology, even though challenging, is not always rewarding. Poor hours, low remuneration and interference with daily schedule are factors known to cause dissatisfaction among those dealing with acute care of the injured”. Attraction of young physicians to this domain and improvement of conditions for those dealing with trauma on a daily basis may contribute to the quality of future trauma surgeons. Data collected in this study only depicts the institutional capability during working hours in the morning. The situation is even worse at night. Sophisticated imaging equipment and experienced radiologists play a vital role in the diagnosis and treatment of the multiple-injury patient:. Almost all hospitals could provide standard X-rays of the cervical spine, chest and pelvis within 5 min. Although most of the hospitals have ultrasound, CT and angiography equipment, few have an organizational structure facilitating rapid accessto the acutely injured patients. Transfer priorities and treatment of unstable trauma cases to the department is difficult and dangerous; when they require sophisticated imaging studies, such as CT scans or angiography, transfer to the X-ray department is unavoidable. The transfer to the X-ray department, and care of the patient should be carried out by an experienced team that includes a responsible surgeon and a skilled trauma nurse. Our study indicated that the availability of standard X-rays is fairly good. However,

46

Injury:

International

there is significant room for improvement in the availability of sophisticated imaging studies. Furthermore, the constant availability of sophisticated imaging equipment, for example, for angiography, is a prerequisite for defining a trauma level I centre. The absence of a national organized trauma registry is one of the major weaknesses of trauma care in Israel. Therefore, there is little reliable data regarding the number, cause, severity and treatment outcome of injuries in Israel. This data is essential for a continuous quality assurance program. At this point, only seven hospitals have an organized trauma registry. A trauma registry is a precondition for level I trauma status certification by the ACS’. The first hospital-based trauma registry was established in Israel in 1995. While significant progress has been made, the establishment of an integrated, nationwide trauma registry is still in progress and the completion of this project remains a challenge for the future. On-line communication between the EMS team in the field and the ED is essential for optimal care. Prior notification of the arrival of a severely-injured patient permits mobilization of the trauma team, blood bank, operating room and the ICU. Prior notification in 375 per cent of cases is received by 66.6 per cent of Israel’s hospitals that deal with trauma care. Improvement in radio-telephone communication between the EMS ambulances and the ED is an important goal for the future. The multiple-injury patient requires the commitment and support of the entire hospital. Trauma care is a continuum which begins in the field and continues in the ED, operating room, X-ray department, ICU ward and the rehabilitation department. It was found that less than half of hospitals caring for trauma patients could guarantee availability of ICU facilities for adult and paediatric trauma patients, including burn victims, at any time. This is probably another indicator of the shortage of ICU beds, when compared to the total number of hospital beds in the country. Israeli hospitals that treat trauma patients should, therefore, increase their flexibility in terms of beds and treatment staff for ICU p,atients. Optimal trauma care requires an organized relationship between community hospitals and regionail tertiary referral centres. Although there are no over\\-helming supporting data, the authors are under the impression that transfer of complex trauma patients to tertiary referral centres is sometimes impeded by lack of resources at the tertiary referral centres.

Journal

of the Care of the Injured

Vol. 29, No. 1,1998

(2) support for establishment of a nationwide trauma registry system; (3) encouragement of young physicians to dedicate themselves to the field of trauma care; (4) increase in the number and ratio of critical-care beds, at least in the tertiary (or level I trauma) centres.

References 1 Smith R. F., FrateschiL., Sloan E. I’. et al. The impact of

volume on outcome in seriously injured trauma patients: two years’ experience of the Chicago trauma system./ Trnwnn 1990; 30: 1066. 2 McNicholl B. I’. and Dearden C. H. Delays in care of the critically injured. Br ] Surg 1992; 79: 171. 3 Driscoll I’. A. and Vincent C. A. Organizing an efficient trauma team. Injury 1992; 23: 107. 4 Rutherford W. H. Reception of severely injured patient at hospital: organizational requirements.Injury 1990; 21: 344. 5 American College of Emergency Physicians. Trauma care systems quality improvement guidelines. Af~rz Enwry Med 1992;21: 736. 6 Ministry of Health Committee on trauma centers in Israel.Ministry of Health, Jerusalem,1992. 7 Resourcesfor optimalc are of the injured patient. Committee of Trauma, American College Of Surgeons, 1990. 8 Sahar A., Shaked I., Findler G. and Hadani, M. Severe head injury - the first hour, evaluation, observation and transportation. Hnrefuah 1988;114:459. 9 Engel Y. Frequency of treatment of upper limb injuries and their cost. Hm$unlr 1988; 14: 153. 10 Marganit B., Rivkind A. and Mackenzie E. J. National systemicapproach for trauma servicesorganization - a way to improve the quality of care to the injured. Hm$ah

1990;

119: 18.

11 ShemerJ. ATLS” course in the development of trauma care in Israel. H~re$~h1995;128:697. I:! Wenneker W. W., Murray D. H. and Leduich T. Improved trauma care in a rural hospital after e>t‘iblishing a level-11trauma center. Am 1 Slrrg 1991; 161: 707. 1: Flint I. Achievement, present-day problems and \ome solutions for trauma care, surgical critical care ‘ind surgicaleducation. Am ] Surg 1991; 161: 207. I-l Turnkey D. D. and Rivkind A. I. An argument tor ‘1 system of trauma care in Israel. lsr ] Med Sci 1991; 27: 173.

Conclusions Since the late 198Os, significant progress has been made in trauma care in Israel. To correct deficiencies identified by the study, the following measures are recommended: (I) continued investment in implementation of an independent trauma unit, both functionally and structurally;

15 Dekeyser F. G., Sheridan M. J. and Trask A. L. Surgeons and trauma care. Resultsof a North American satisfaction survey. I Trnwrza 1996; 131: 627. Paper accepted 15 September 1997. for reprints should be addressed to: Mr M. Stein, 13 Hakabaim Str, Apt #12, Ramat-gan52255,Israel. Tel./Fax: 972-3-5747363; E-mail:mgmg~stein~~netvision.net.il. Requests