The major trauma management study: an analysis of the efficacy of current trauma care

Low major trauma confidence among emergency physicians working outside major trauma services: Inevitable result of a centralised trauma system or evidence for change?

OBJECTIVE

Regionalised civilian trauma systems improve patient outcomes, but may deskill clinicians outside major trauma services (MTSs). We aimed to characterise experience and confidence in trauma management among emergency physicians working in MTS to those working elsewhere.

METHODS

Emergency physicians working within the Victorian State Trauma System were surveyed about their pre- and post-fellowship training experience, their estimated hours per fortnight in different centres, the frequency of performance/supervision of critical emergency skills and their confidence in a range of trauma skills.

RESULTS

The 138 respondents analysed represented 33% of active Victorian FACEMs. The cohort were mostly males (69.6%), younger than 50 (75.4%) and were generally (69.6%) six or more years post-fellowship. FACEMs working in a MTS were more likely to have been a trauma registrar prior to fellowship (13.3% vs 3.7%, P = 0.046). MTS clinicians performed more, supervised more and were more confident in trauma team leading, traumatic airway management and rapid infusion catheter and multi-access catheters. Confidence in trauma team leading was only associated with exposure to performance or supervision of trauma team leading. Performance of trauma team leading was more common in clinicians at a MTS (odds ratio 3.19, 95% CI 1.00-10.20, P = 0.05).

CONCLUSION

Exposure to major trauma is associated with time spent working in a MTS and exposure is associated with confidence. A mature inclusive trauma system must ensure clinicians across the system gain the experience or training to provide trauma care that will result in similar outcomes for patients regardless of initial presenting hospital.

Morbidity and mortality meetings at Australian major trauma centres: A proof of concept study

Background

Morbidity and mortality meetings are held at all Australian major trauma centres and provide a forum to identify problems and improve practices. Meetings should focus on addressing factors in the system to prevent similar errors occurring, rather than individual culpability. This paper describes current meeting practices and assesses the use of a systems approach.

Methods

This proof of concept study used a convenience sample of four Australian major trauma centres. Trauma leaders at each centre were surveyed regarding morbidity and mortality meeting practices. The use of a systems approach was measured by assessing practices against the London Protocol for Systems Analysis of Clinical Incidents. Meeting participants were also surveyed regarding perceptions of the objectives and effectiveness of meetings.

Results

This study found variable utilisation of a systems approach. Cases are not routinely analysed for contributing system factors and effective processes are not always used to correct problems that are identified. Meeting practices also vary between centres in terms of frequency, case selection criteria and use of audit filters. Participants generally view quality improvement as the most important objective of meetings.

Conclusion

Morbidity and mortality meeting practices vary between Australian major trauma centres and a systems approach has not been fully adopted.

Perceptions of an educational programme for registered nurses who work at non-major trauma services in Victoria, Australia: The Nursing Emergency eXternal Trauma Programme

BACKGROUND

Emergency nurses working in non-Major Trauma Service (non-MTS) facilities face the challenge of providing immediate care to seriously injured patients, despite infrequent presentations at their workplace. A one-day education programme endorsed by the Australian College of Nursing was developed to provide contemporary trauma education for nurses. The aim of this study was to report participants' perceptions of their experience of this programme.

METHODS

Peer reviewed lesson plans were developed to guide educational activities. Of 32 participants, 24 consented to and completed pre and post-programme surveys. Thematic analysis and descriptive statistics were used to report study findings.

RESULTS

Most participants were nurses with greater than two years' experience in Emergency Nursing (92%). Trauma patient transfers each year from a non-MTS to a Major Trauma Service occurred infrequently; eight nurses (33.3%) reported greater than10 trauma transfers per year. Participant expectations of the programme included personal growth, knowledge acquisition, increased confidence and a focus on technical skills. Participants reported the day to be worthwhile and valuable; improved confidence, increased knowledge, and the opportunity to discuss current evidence based practice were highly regarded. Recommendations for future programmes included extending to two days and include burns and more complex pathophysiology.

CONCLUSIONS

With centralisation of trauma care to major trauma services, frequent and continuing education of nurses is essential. Nurses from non-Major Trauma Service facilities in Victoria found this programme worthwhile as they gained knowledge and skills and increased confidence to care for trauma patients.

Paediatric and adolescent trauma care within an integrated trauma system

BACKGROUND

The aim of this study was to establish the profile and outcomes of paediatric major trauma care (PTMC) within an integrated inclusive regionalised trauma system.

METHODS

Prospectively collected data from July 2001 to June 2009 from the Victorian State Trauma Registry of patients aged <18 years were reviewed.

RESULTS

There were 1634 major trauma cases with a median (IQR) age of 13 (6-16) years and 69% were male. The median ISS (IQR) was 18 (16-26). There were 1361 patients treated at a major trauma centre of which 69% (n=943) were treated at the PMTC. Head injury (AIS>2) was the most frequent injury (n=950, 58%). Surgery was required in 39% (n=637) of all cases; 437 patients in the 10-17 year old group and 200 patients in the 0-9 year old group; the mortality was 6.6%. There were 530 patients (32.4%) ventilated in ICU; these had a median ISS (IQR) of 25 (17-34) and mortality of 7.4%. Improvements in risk-adjusted mortality have occurred as the years have progressed [adjusted OR 95% CI: 0.87 (0.76, 0.99)] and being treated at a Level 1 trauma centre was associated with lower adjusted odds of mortality [adjusted OR 95% CI: 0.27 (0.11, 0.68)].

CONCLUSION

The establishment of this integrated inclusive regionalised trauma system has been associated with progressively improving risk-adjusted mortality. The relatively low volume of major trauma requiring surgery in the 0-9 year old age group is notable, creating a challenging environment for maintaining skills and institutional preparedness.

Trauma Incidents Attended by Emergency Medical Services in Victoria, Australia

Introduction:

International literature describing the profile of trauma patients attended by a statewide emergency medical services (EMS) system is lacking. Most literature is limited to descriptions of trauma responses for a single emergency medical service, or to patients transported to a specific Level-1 trauma hospital. There is no Victorian or Australian literature describing the type of trauma patients transported by a state emergency medical service.

Purpose:

The purpose of this study was to define a profile of all trauma incidents attended by statewide EMS.

Methods:

A retrospective cohort study of all patient care records (PCR) for trauma responses attended by Victorian Ambulance Services for 2002 was conducted. Criteria for trauma categories were defined previously, and data were extracted from the PCRs and entered into a secure data repository for descriptive analysis to determine the trauma profile. Ethics committee approval was obtained.

Results:

There were 53,039 trauma incidents attended by emergency ambulances during the 12-month period. Of these, 1,566 patients were in physiological distress, 11,086 had a significant pattern of injury, and a further 8,931 had an identifiable mechanism of injury. The profile includes minor trauma (n = 9,342), standing falls (n = 20,511), no patient transported (n = 3,687), and deceased patients (n = 459).

Conclusions:

This is a unique analysis of prehospital trauma. It provides a baseline dataset that may be utilized in future studies of prehospital trauma care. Additionally, this dataset identifies a ten-fold difference in major trauma between the prehospital and the hospital assessments.

Preventability of trauma deaths in a Dutch Level-1 trauma centre

BACKGROUND

Monitoring the quality of trauma care is frequently done by analysing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center trauma deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma centre for (potential) preventability.

METHODS

All patients who died during or after presentation in the trauma resuscitation room in a 2-year period were eligible for review. All information on trauma evaluation and management was summarised by an independent research fellow. An external multidisciplinary panel individually evaluated the cases for preventability of death. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the external panel and the internal M&M consensus.

RESULTS

Of the 62 evaluated trauma deaths one was judged as preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the internal consensus was moderate (Kappa 0.51). The external panel judged one death as preventable compared with three from the internal consensus. The interobserver agreement between the external panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Such errors included choice or sequence of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies.

CONCLUSIONS

The preventable death rate in the present study was comparable to data in the available literature. Compared to internal review, the external, multidisciplinary review did not find a higher preventable death rate, although it provided several insights to optimise trauma care.

Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria

BACKGROUND

There is a paucity of literature comparing trauma patients who meet pre-hospital trauma triage guidelines ('potential major trauma') with trauma patients who are identified as 'confirmed major trauma patients' at hospital discharge. This type of epidemiological surveillance is critical to continuous performance monitoring of mature trauma care systems. The current study aimed to determine if the current trauma triage criteria resulted in under/over-triage and whether the triage criteria were being adhered to.

METHODS

For a 12-month time period there were 45,332 adult (≥16 years of age) trauma patients transported by ambulance to hospitals in metropolitan Melbourne. This retrospective study analysed data from 1166 patients identified at hospital discharge as 'confirmed major trauma patients' and 16,479 patients captured by the current pre-hospital trauma triage criteria, who did not go on to meet the definition of confirmed major trauma. These patients comprise the 'potential major trauma' group. Non-major trauma patients (N=27,687) were excluded from the study. Pre-hospital data was sourced from the Victorian Ambulance Clinical Information System (VACIS) and hospital data was sourced from the Victorian State Trauma Registry (VSTR). Statistical analyses compared the characteristics of confirmed major trauma and potential major trauma patients according to the current trauma triage criteria.

RESULTS

The leading causes of confirmed major trauma and potential major trauma were motor vehicle collisions (30.1% vs. 19.2%) and falls (30.0% vs. 48.7%). More than 80% of confirmed major trauma and 24.4% of potential major trauma patients were directly transported to a major trauma service. Overall, similar numbers of confirmed major trauma patients and potential major trauma patients had one or more aberrant vital signs (67.0% vs. 66.4%). Specific injuries meeting triage criteria were sustained by 69.2% of confirmed major trauma patients and 51.4% of potential major trauma patients, while 11.7% of confirmed major trauma patients and 4.6% of potential major trauma patients met the combined mechanism of injury criteria.

CONCLUSIONS

While the sensitivity of the current pre-hospital trauma triage criteria is high, if paramedics strictly followed the criteria there would be significant over-triage. Triage models using different mechanistic and physiologic criteria should be evaluated.

The Victorian major trauma transfer study

AIMS

To comprehensively examine the inter-hospital transfer of major trauma patients-including the reason for transfer, duration, escorts, interventions and unexpected events.

METHODS

This was an detailed study of the transfer of major trauma cases in the State of Victoria, Australia, between April 16, 2003 and December 31, 2004. Twenty-three hospitals and seven transfer/retrieval services participated. Defined major trauma cases that were transferred between participating hospitals for the purpose of definitive care were eligible for enrolment. The transfer phase extended from 30 min before until 30 min after the transfer. The transferring and receiving hospitals and the transfer escorts were asked to record data on a specifically designed data collection form.

RESULTS

A total of 451 cases were enrolled (mean Injury Severity Score 22.2). Transfers originated mainly from Regional Trauma (42.8%) and Metropolitan Trauma (31.3%) Services and most (90.5%) terminated at a Major Trauma Service. Median time from injury to arrival at the receiving hospital was 8 h 30 min. Median time from arrival at referring hospital to request for transfer was 3 h 25 min. Escorts comprised ambulance and medical/nursing staff in 67.0% and 30.4% of cases, respectively. Metropolitan retrieval services were involved in only 10% of cases. Medical escorts were mainly (62.9%) from the referring hospital and the majority of these were registrars (49.4%) and hospital medical officers (HMOs, 16.9%). Overall mortality was 6.2%. Mortality rates for cases escorted by referring hospital doctors, Mobile Intensive Care Ambulance (MICA), non-MICA and any other escorts were 14.5%, 6.0%, 2.6% and 4.3%, respectively. HMO escorts had the highest mortality risk (OR 3.67, 95%CI 1.00-13.49, p<0.001). Mortality risk was greatest for cases that required administration of vasopressor drugs (OR 11.4, 95%CI 3.78-34.36, p<0.001), intubation prior to arrival at the referring hospital (OR 10.36, 95%CI 3.51-30.52, p<0.001), any interventions at the referring hospital (OR 8.3, 95%CI 3.1-22.2, p<0.001), administration of blood at the receiving hospital (OR 4.91, 95%CI 1.5-16.1, p=0.01), and cases using escorts from the referring hospital (OR 3.8, 95%CI 1.69-8.39, p=0.001).

CONCLUSION

Considerable variability in request for transfer and transfer times, transfer escorts and mortality risk exist. The single greatest issue identified that most severely injured group were escorted by the most junior doctors (HMOs) and had the highest mortality. This crucial issue must be addressed by the State Trauma System and by any redesigned retrieval service in Victoria. A detailed review of activation and responsiveness criteria and the nature of the transfer escort is indicated. The establishment of Adult Retrieval Victoria may address many of the concerns raised by this study.

Comparison of quality control for trauma management between Western and Eastern European trauma center

Background

Quality control of trauma care is essential to define the effectiveness of trauma center and trauma system. To identify the troublesome issues of the system is the first step for validation of the focused customized solutions. This is a comparative study of two level I trauma centers in Italy and Romania and it has been designed to give an overview of the entire trauma care program adopted in these two countries. This study was aimed to use the results as the basis for recommending and planning changes in the two trauma systems for a better trauma care.

Methods

We retrospectively reviewed a total of 182 major trauma patients treated in the two hospitals included in the study, between January and June 2002. Every case was analyzed according to the recommended minimal audit filters for trauma quality assurance by The American College of Surgeons Committee on Trauma (ACSCOT).

Results

Satisfactory yields have been reached in both centers for the management of head and abdominal trauma, airway management, Emergency Department length of stay and early diagnosis and treatment. The main significant differences between the two centers were in the patients' transfers, the leadership of trauma team and the patients' outcome. The main concerns have been in the surgical treatment of fractures, the outcome and the lacking of documentation.

Conclusion

The analyzed hospitals are classified as Level I trauma center and are within the group of the highest quality level centers in their own countries. Nevertheless, both of them experience major lacks and for few audit filters do not reach the mmum standard requirements of ACS Audit Filters. The differences between the western and the eastern European center were slight. The parameters not reaching the minimum requirements are probably occurring even more often in suburban settings.

‘Talk and Die’ patients presenting to a major trauma centre over a 10 year period: A critical review

'Talk and die patients' describes a small number of patients who present with a mild head injury (Glasgow Coma Scale [GCS] 13-15) and then subsequently deteriorate and die from intracranial causes. We analysed the medical records of all those adult patients whose primary diagnosis as the cause of death was head injury, as determined by the coroner, who were admitted to a major Australian trauma centre between January 1994 and December 2003 (a 10-year period). The clinical profile of those patients who fulfilled the criteria of 'talk and die' were documented, including age, mode of injury, initial GCS, lucid interval, CT scan reports, operation performed, post mortem findings and intracranial cause of death. Factors considered potentially contributory to the patients' deterioration, such as delays in CT scanning or patient transfer, coagulopathy or hypoxic episodes were also noted. The incidence of 'talk and die' patients was 2.6% (15 out of 569) overall and the annual incidence did not significantly alter over the 10-year period of the study. The small number of patients precludes inferences regarding causal relationships, although potentially preventable factors, which could have been contributory to patient deterioration, were identified.

The evolution of an integrated State Trauma System in Victoria, Australia

The incidence of major trauma and associated fatalities in the State of Victoria, Australia, have declined over 20 years following the successful implementation of strategies to modify environmental and behavioural factors that contribute to motor vehicle injuries. However, several system deficiencies in the management of major trauma patients had remained unresolved. To investigate these shortfalls the State Government of Victoria established a task force in 1997 to review trauma and emergency services. The task force adopted the principle of "the right patient to the right hospital in the shortest time" and in 2000 began to deploy an integrated State Trauma System. Implementation of such a system required the designation of specific hospitals of various levels to care for trauma patients; the concentration of trauma expertise at these centres; integration and coordination between the service providers; development of agreed triage and transfer protocols and improved education, training and research programs. A statewide major trauma database was established to enable system monitoring and facilitate further enhancements. The Victorian experience with the development of an integrated trauma system should aid in the development of similar systems nationally and internationally and is described in this paper.

Trauma bypass in south-eastern Sydney: An 8-year review

OBJECTIVE

The New South Wales (NSW) Health Department and the Ambulance Service of NSW introduced a trauma bypass system in Sydney on 29 March 1992. This study aims to review the outcomes of trauma bypass patients brought to St George Hospital, a major trauma service in south-eastern Sydney, and to assess the performance of the current prehospital trauma triage protocol.

METHODS

The St George Hospital Department of Trauma Services prospectively collected data on all trauma bypass patients for the 8-year period from 29 March 1992 to 29 March 2000.

RESULTS

A total of 1990 patients were brought to hospital on trauma bypass. The average age was 32 years, 70% were men and 66% were from road traffic accidents. The positive predictive value of the prehospital triage tool for serious injury (Injury Severity Score [ISS] > 15) was 18.6% (95% CI 16.9-20.4). This is well below the benchmark previously established by the NSW Health Department Trauma System Advisory Committee. For all trauma bypass patients, 33.8% (95% CI 31.7-35.9) were discharged home from the ED. The overall death rate was 2.5% (95% CI 1.9-3.3).

CONCLUSIONS

According to the proposed benchmark, current prehospital trauma triage guidelines are underperforming. This suggests that a review of the benchmarks of current local trauma systems and of the trauma triage tool is required.

Developing Australia's first statewide trauma registry: what are the lessons?

Trauma registries, like disease registries, provide an important analysis tool to assess the management of patient care. Trauma registries are well established and relatively common in the USA and have been used to change legislation, promote trauma prevention and to evaluate trauma system effectiveness. In Australia, the first truly statewide trauma registry was established in Victoria in 2001 with an estimated capture of 1700 major trauma cases annually. The Victorian State Trauma Registry, managed by the Victorian State Trauma Outcomes Registry and Monitoring (VSTORM) group, was established in response to a ministerial review of trauma and emergency services undertaken in 1997 to advise the Victorian Government on a best practice model of trauma service provision that was responsive to the particular needs of critically ill trauma patients. This taskforce recommended the establishment of a new system of care for major trauma patients in Victoria and a statewide trauma registry to monitor this new system. The development of the Victorian state trauma registry has shown that there are certain issues that must be resolved for successful implementation of any system-wide registry. This paper describes the issues faced by VSTORM in developing, implementing and maintaining a statewide trauma registry.

The status of the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) was first introduced in the 1970s to provide a simple and reliable method of recording and monitoring change in the level of consciousness of head injured patients. Since its introduction, the GCS has been widely utilized in the trauma community and its use expanded beyond the original intentions of the score. In the context of traumatic injury, this paper discusses the use of the GCS as a predictor of outcome, the limitations of the GCS, the reliability of the GCS and potential alternatives through a critical review of the literature. The relevance to Australian trauma populations is also addressed.

Predicted impact on Victoria's ambulance services of a new major trauma system

BACKGROUND

In 1999, a new major trauma system was proposed for the state of Victoria, Australia. The guidelines for the new system were aimed at delivering major trauma cases to definitive trauma care in the least time possible. The aim of the present study was to analyse the potential effect of this system on Victoria's ambulance services.

METHODS

The present study modelled the workload of major trauma cases in Victoria's ambulance service for one year pre- and post-introduction of the guidelines. Cases were analysed regarding whether their first hospital destination would change under the proposed guidelines, and, subsequently, whether they would require interhospital transport to a higher level trauma service. The impact on the ambulance services was modelled as annual changes in distances travelled due to predicted changes in hospital destinations.

RESULTS

Analysis of the predicted changes indicated that, in general, Victoria's metropolitan and rural road ambulance crews would not be greatly affected. However, some metropolitan road crews may have to travel extra distances for up to 110 cases per year. The major impact was on air retrieval crews, where the annual number of interhospital transfers is predicted to increase from approximately 150 to 330.

CONCLUSIONS

The present study demonstrated that most of the impact of a new trauma system on Victoria's ambulance services could be readily absorbed into the current workload. However, it also highlighted areas affected disproportionately within the ambulance services; in particular, air retrieval. Such studies are important to enable the effective implementation of new trauma systems.

Trauma training in Australia and New Zealand: results of a survey of advanced surgical trainees

BACKGROUND

The surgical management of trauma within Australia and New Zealand has recently been undergoing major organizational changes. The aim of the present paper was to evaluate the attitudes and experience of Australian and New Zealand advanced surgical trainees in this changing climate and to identify problems with trauma training.

METHODS

A survey assessing important areas of trauma management and training was sent to all advanced surgical trainees of the Royal Australasian College of Surgeons.

RESULTS

Two hundred and seventy-two of 587 trainees responded (46%). Overall 85% of trainees believed they would be involved in trauma management in the future. The majority of trainees reported low rates of involvement and consultant supervision in trauma resuscitations. Only 32% of general surgical trainees believed that their exposure to major trauma operations was very adequate despite an average of 12.3 trauma operations per year. Seventy per cent of general surgical trainees reported a very adequate level of consultant supervision at trauma operations. In contrast 86% of orthopaedic trainees reported a very adequate exposure to trauma operations with an average of 221 orthopaedic trauma operations per year. Only 46% of orthopaedic trainees reported a very adequate level of consultant supervision at trauma operations.

CONCLUSIONS

Regional rotations may need to be developed to even out trainees' experience in trauma management. The low level of supervision in trauma resuscitations and orthopaedic surgical training requires attention. This survey warrants repeating in a prospective manner.

Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital

OBJECTIVE

To investigate the nature and duration of clinical instability (i.e., abnormalities in simple physical observations or laboratory test results) in hospital patients before a "critical event" (i.e., a cardiac arrest or an unplanned admission to intensive care).

DESIGN

Retrospective survey of medical records of all patients having critical events (CEs) over 12 months. Data on hospital and Intensive Care Unit (ICU) patients were obtained for comparison with the study population.

SETTING

A 300-bed metropolitan teaching hospital with a seven-bed ICU.

PATIENTS

All patients having CEs over a 12-month period (January to December 1997).

MAIN OUTCOME MEASURES

Number of patients with clinical instability before a CE; duration of clinical instability before a CE; number of medical reviews of each patient before a CE; mortality rate and length of hospital stay for all patients.

RESULTS

There were 122 CEs in 112 patients (median, 1; range, 1-4). Of the CEs, 79 were unplanned ICU admissions (14 subsequent to cardiac arrest calls), and 43 were cardiac arrest calls not resulting in ICU admission. Each CE was preceded by a median of two (range, 0-9) criteria for clinical instability. The median duration of instability before a CE was 6.5 hours (range, 0-432 hours), and in that time a median of two (range, 0-13) medical reviews took place. The incidence of CEs in the total hospital population (122 CEs/19,853 admissions) and in ICU patients (79 unplanned admissions/515 admissions) was 0.6% and 15%, respectively. There were 70 deaths (62%) among the 112 patients, compared with a total of 392 deaths (2% of admissions) in the hospital, of which 107 were in ICU.

CONCLUSIONS

Very few patients suffer a CE while in hospital. However, those who do frequently manifest abnormalities in simple physical observations and laboratory test results before the CE. More rapid intervention in response to warning signs might provide a better outcome for these patients.

Management of severe trauma in intensive care units and surgical wards

OBJECTIVE

To evaluate the management of severe trauma in intensive care, high dependency and general surgical wards of Victorian hospitals.

DESIGN

Retrospective case review by multidisciplinary committees.

SUBJECTS

The first 256 people who died from road traffic accidents who were alive on the arrival of emergency services between 1 July 1992 and 30 June 1994.

MAIN OUTCOME MEASURES

(1) Severity of injury according to clinical diagnosis, autopsy findings and recognised trauma-scoring methods; (2) errors in management, identified as contributing or not contributing to the cause of death, and categorised as "management", "system", "diagnostic" or "technique" errors.

RESULTS

Most patients (61%) were admitted to an intensive care unit (ICU), and 19.5% were admitted to high dependency or general surgical wards. Of 2187 errors of care identified, 11.8% occurred in ICU and 6.7% in wards, with the remainder occurring during the earlier phases of care. Most errors were classified as management errors (82% of ICU errors and 88% of ward errors). Fifty-two per cent of ICU errors and 71% of ward errors were judged to contribute to the patient's death.

CONCLUSIONS

A significant number of errors of trauma management occur in the intensive care and general surgical ward. Improvement in late trauma care may reduce the number of preventable trauma deaths.

Quality in healthcare in the United Kingdom: lessons for Australia

The United Kingdom has a strong emphasis on quality in healthcare and clinical audit. Many quality activities are funded by the government but managed by professional bodies, a model that should be trialed in Australia.