The future of trauma development in Hong Kong: Putting the patient first

Surgical Practice doi:10.1111/j.1744-1633.2010.00507.x Letter to the Editor The future of trauma development in Hong Kong: Putting the patient first ash_507 120..121 Dear Editor, It was with both interest and deep appreciation that I read the recent article by Leung describing the historical development of a trauma system in Hong Kong.1 Fifteen years ago, Professor Trunkey recommended that a more systematic process for managing trauma patients be developed in Hong Kong and we have seen progress with the introduction of five trauma centres, a centralized trauma database, a much more coordinated approach, the introduction of primary trauma diversion, and an increase in overall trauma survival. However, although much has been done, the signs of improvement are not as positive as may appear at first sight. In fact, the progress of development of trauma management in Hong Kong has been slow and delayed. Those who suffer the most are our patients. In 2000, a review by a panel of overseas experts advised that the volume of major trauma in Hong Kong was insufficient to justify more than two or three trauma centres in the region. The community as a whole is best served, and optimal survival achieved, when resources and expertise are concentrated in a minimum (i.e. two or three) rather than in a maximum number of trauma centres. When patients with major trauma are concentrated in centres of excellence, trauma surgeons and physicians acquire a much higher level of experience than when cases are diluted among several centres where few, if anyone, develops expertise in any one area. In Hong Kong, just as elsewhere, other factors such as personal agendas, politics, clustering, ‘training’ and territorialism are put before optimal patient care. When modern survival figures after trauma in Hong Kong are compared with average standards in the US Major Trauma Outcome Study,2 Hong Kong today is little better than the US average of 15 years ago, and a long way behind the leading US trauma centres. It is important to understand the figures quoted by Leung show that survival after trauma in Hong Kong is just beginning to reach a level which is no better than the US average of 15 years ago. Should a world-class city, and an Asian leader, such as Hong Kong, settle for average standards of health care? I affirm Leung’s call that triaging the right trauma patient to the right hospital rather than to the nearest hospital, and in the shortest possible time, should be our goal. The process of implementing primary trauma diversion in Hong Kong should not stall half-way but should be completed as soon as possible. Our intelligent and well-trained ambulance and fire services are well up to this task but there needs to be greater transparency about their current processes of care. Trauma centres should receive advanced warning of the arrival or transfer of trauma patients. Hong Kong has one of the best telecommunication systems in the world and, yet, it is rare that the trauma centre will be alerted of the likely time and the condition of a trauma case. Transparent sharing and audit of data will lead to greater accountability and responsible progress. Leung rightly hints that whereas Hong Kong has designated trauma centres, designation does not equal quality. A high-quality service is achieved by an open and serious attitude, by shared and honest data, and fair and sincere audit and appraisal. These are not achieved by designation, but rather by accreditation. Regular and independent peer review of preventable deaths should be initiated in Hong Kong. Trauma deaths may be classified into three levels: preventable deaths, possible preventable deaths and nonpreventable death. For ‘possible preventable death’ and ‘preventable death’, the ‘system problems’ or ‘process problems’ need to be identified and necessary related education and action are needed to improve clinical practice. In regular trauma audit meetings, the doctor in charge of the case should be responsible for giving the case presentation. There needs to be 3-yearly verification of trauma centres. Further, in order to ensure that the whole system is indeed working well, trauma data from non-designated trauma centres should be reviewed with particular reference to trauma mortality. Evaluating only trauma centres means that patients not transferred to such centres are not included in system assessment. When parts of a system are not assessed they are likely not to function as well. For all of us, it is much more comfortable and convenient not to face the truth of independent and unbiased audit, but it is in our patient’s interest to do so. Surgical Practice (2010) 14, 120–121 © 2010 The Author Journal compilation © 2010 College of Surgeons of Hong Kong Letter to the Editor Hong Kong has an increasingly elderly population and studies on elderly trauma are important. Independent living quality indicators of elderly patients surviving to discharge should be reviewed using, for example, Functional Independent Measures/Glasgow Outcome Scale (FIM/GOS), taken at discharge and at 3 and 6 months of discharge. Other areas of care or research, which may improve trauma outcomes, include the introduction of massive transfusion protocols, early computed tomography of the head, neck, chest, abdomen and pelvis, as appropriate, and all completed within 15 min of arrival, a lower threshold for admission to, and better use of, ICU beds, assessment of the quality of our rehabilitation programmes, and a psychological service for patients and their relatives. A designated operating theatre (OT) nurse should attend the resuscitation room as part of the trauma call in order to expedite the process leading to ‘immediate’ surgery. Emergency patients should leave the trauma room to definite care (e.g. OT) within 15 min of arrival. The OT room should be available within 5–15 min. Do we need a trauma surgeon? As things stand in Hong Kong, there may be little value in introducing trauma surgeons as there is insufficient work in any one hospital to justify their existence or keep them interested. However, if the Hospital Authority should make the decision to centralize trauma care for major trauma cases into two or three trauma centres, then the trauma surgeon would be invaluable. The two university teaching hospitals are responsible for teaching and training and so, probably, should have a trauma centre role. In the last 5 years, Oregon County, USA has reduced trauma centres from five to two. The main 121 reason has been accountability to government and to the public for the use of resources. Trauma teams in the USA are undergoing radical restructuring. The main purpose for having a trauma team and trauma call is to expedite life-saving procedures or surgery. The leading causes of early preventable death after major trauma are head, chest and abdominal injury. Although limb injury is common, it is rarely imminently life-threatening. An emergency physician is capable of managing some of these lifesaving and airway procedures. With this in mind, many trauma teams standing by in emergency departments in the USA now involve only two general surgeons. There are no orthopaedic surgeons or anaesthetists on the team. Concentrating care into two or three centres may justify introducing an experienced neurosurgeon or cardiothoracic surgeon to the team. Much needs to be done and much could be done if our managers had a will to face the challenges before us. As always, the patient, rather than personal and political agendas, should come first. Timothy Rainer Director, Accident and Emergency Medicine Academic Unit, CUHK and Honorary Chief of Service, Department of Accident and Emergency Medicine, Prince of Wales Hospital, Hong Kong References 1. Leung GKK. Trauma system in Hong Kong. Surg. Pract. 2010; 14: 38–43. 2. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. Journal of Trauma 1987; 27(4): 370–8. Surgical Practice (2010) 14, 120–121 © 2010 The Author Journal compilation © 2010 College of Surgeons of Hong Kong