Complexity and simplicity: Federal Government to create seven trauma centres across Nigeria
In Nigeria, few victims receive treatment at the scene and fewer still can hope to be transported to the hospital in an ambulance. Transport, when it is available, is usually provided by relatives, untrained bystanders, taxi drivers or truck drivers, or police officers. As a result, many victims may needlessly die at the scene or during the first few hours following injury.
Prevention: “Injury does not occur by accident”
Deaths occurring in the immediate point of injury cannot be directly prevented by improving the quality of prehospital care and hospital-based emergency care, but an organized system of care may support injury prevention efforts by systematically collecting data that are useful for implementing prevention programs, such as identifying high- risk settings, high-risk behaviors, high-risk products and high-risk individuals and groups.
The trauma center should use the trauma registry to identify the pattern, frequency and risks for injury within the community. Trauma centers working together with prehospital providers, rehabilitation experts, local community groups, governmental agencies, national organizations, private foundations and public health schools can have a significant impact on lessening the morbidity and mortality of trauma.
Injury prevention falls into 3 categories; primary prevention strategies are designed to prevent the occurrence of the injury itself like speed limits, Driving Under the Influence of alcohol laws and firearms regulations. Secondary prevention measures seek to limit energy transfer to the individual, thus minimizing the severity of the injury, like crash helmets or seat belts while tertiary prevention is targeted at improving outcome following injury e.g hospital triage at trauma centers.
Traditionally prevention endeavors have focused on education to enhance the acceptance by government and society of scientifically proven safety measures and prevent blockage by political issues; enactment of safety laws, their enforcement and environmental modification
The Gold standard: Trauma system
A trauma system is an all-encompassing trauma management approach that integrate all the components of injury prevention and control, access, acute hospital care, rehabilitation and research activities for a defined region. Central to an ideal system is a large, resource-rich trauma center. The need for resources is based primarily on the concept of being able to provide immediate availability of emergency physicians, general surgeons, anesthesiologist, neurosurgeons and orthopedic surgeons.
Trauma systems once implemented improve the quality of trauma care. In addition to reducing the number of “preventable deaths”, a trauma system improves the outcome of the most severely injured patients, quality of care, overall reduction of mortality rates from injuries and reduction in social and economic burden of injury.
There are several basic elements involved in the development and organization of a trauma system; from decades of lessons learnt in the evolution of trauma services from North Americas and as put forward in the guidelines of the American College of Surgeons Committee Of Trauma ACS-COT (Resources for optimal care of the injured patient.)
An essential foundation is public education and support, which provide the basis for enacting legislation that establishes the structure of the system, including a lead agency, the authority of the lead agency, and funding to support the enterprise. Enabling legislation for system development is necessary to establish a lead agency with the authority to operate the system, develop and enforce standards, designate specialized facilities, and ensure the provision of appropriate services. This step is coupled with legislative education, by the professional community and advocacy by community interest groups.
A needs assessment study complements public education and the development of public support by establishing the magnitude of the burden of injury in a community and the need for improved trauma care. Resources available within the region are compared with the anticipated needs of a trauma system, thereby defining the gap that exists between the two. This gap analysis would be used by health planners to identify specific deficiencies and develop feasible solutions for the system.
Development of trauma plan by the lead agency in conjunction with the appropriate professional and community advisory groups is necessary to provide an overall blueprint for the design, implementation and ongoing development of trauma care system. Such a plan may outline the organizational structures, system components, basis for system standards, specific objectives of the system, and a means of evaluating and improving system performance.
Evaluation, verification and designation of trauma centers involve an assessment of the trauma centers within a system to ensure that they meet the standards set by the lead agency. The verification process may be internal, conducted by the lead agency or external, conducted by an agency or organization authorized by the lead agency. This would allow designation of acute care facilities, a process which allows exclusivity and reflects the lead agency’s authority to exclude and limit non-designated facilities or system components from provider care. Ultimately the quality and consistency of various components of care would be regulated through the designation and verification process.
Trauma system evaluation and performance improvement require a defined program based on a trauma registry, system wide medical audit process, and an appropriate committee structure with broad membership. The purpose of the program is to ensure that the various elements of the trauma system are operating in an organized, coordinated manner that improves the overall outcomes from traumatic injury.
The trauma center should have an integrated, concurrent performance Improvement and patient safety (PIPS) program to ensure optimal care and continuous improvement in care.
Trauma centers must be able to provide the necessary human and physical resources to properly administer acute care consistent with their level of verification.
Guidelines categorize facilities that manage trauma patients into four levels of care. Levels I, II, III and IV. This categorization is based on the resources available, extent of population served, severity of injuries managed, research and training activities
A hospital administrative structure must support the trauma program. This would help provide adequate resources for the optimal care of the injured patients. Medical staff commitment ensures that the members of the medical staff support the trauma program by their professional activities.
The trauma program involves multiple disciplines that transcend normal departmental hierarchies. Because trauma care extends from the scene of injury through the acute care setting to discharge from a rehabilitation center, with appropriate specialty representation from all phases of care.
Rehabilitation is important to restore the patient to pre-injury status or preservation of optimal functional recovery. Not only is this effort best for the patient, it is also less costly. When rehabilitation results in independent patient function, there is 90% cost saving compared with costs of custodial care and repeated hospitalizations.
Maintaining a trauma registr y is essential, as this contains detailed, reliable and readily accessible information needed to operate a trauma center for performance improvement, injury prevention activities, outcome measurements, resource utilization, cost analysis and research.
Trauma research and scholarship is fundamental for discovery of new devices, strategies etc for improvement in patients care, leadership in major traumarelated organizations, funding, dissemination of information, application of clinical knowledge, participation in clinical discussion and conferences, support of resident participation in scholarly activities, mentorship of junior faculty, residents and fellows.
Case study; National Trauma Center, National Hospital, Abuja
The national Trauma center commissioned in august 2014, as a critical component of a Nigeria’s healthcare delivery system, to provide resources and equipment to deliver the full range of specialist care needed by severely injured patients, and also maintain coordination with other facilities where the need for complementary expertise may be indicated. It started operation with great enthusiasm, hope for better care for injured patients and other perceived benefits like structured trainings in trauma like Advanced Trauma Life Support ATLS, Definitive Surgical Trauma Care DSTC, Advanced Burns care Life Support ABLS, Pre Hospital Trauma Life Support PHTLS, fellowships in trauma, trauma nursing critical care leadership in trauma services coordination.
To this day about 3000 patients of various severities of injuries were managed at the center. The patients for lack of organized Emergency Medical Services EMS or prehospital trauma services, are brought to the center by different categories of emergency care providers; police most often in their patrol pick-up vans, ambulances of Federal Road Safety Corps FRSC, National Emergency Management Agency NEMA, and Nigerian Civil Defense Corps NSDC. This, in contrast to an organized EMS result in a lot of inconsistencies and inefficiencies in services, duplicities and wastages of human and financial resources.