Model trauma system policy
These recommendations were developed at the Meeting to Promote Implementation of the Guidelines for Essential Trauma Care, 10-11 June, 2004, WHO HQ, Geneva. The recommendations represent a consensus of the participants as to what most countries should consider having in place within their overall health policy to assure minimum standards for care of the injured.
The purpose of this set of policy recommendations is to assure that all injured patients receive essential life and limb saving care in an appropriate and timely fashion. Essential items of care are defined in related WHO publications, including Guidelines for Essential Trauma Care and Prehospital Trauma Care Systems. Such essential services should be provided to all who need them without regard for ability to pay. This does not preclude the possible need for cost recovery, as appropriate, after essential services have been rendered.
A responsible person or unit within the ministry of health or other appointed agency should be clearly defined as being in charge of assuring the minimum standards of trauma care for that country. The personnel involved should have the necessary administrative skills and understanding of clinical trauma care issues. The department should have adequate resources and legal mandate to undertake its work. This department should work in a multi-sectoral, multi-disciplinary collaborative manner with other stakeholders in trauma care, including representatives of pertinent professional societies, other government agencies such as transport and justice, and communities.
In locations where there is currently no formal emergency medical services (EMS, or ambulance service):
- Governments should undertake systematic reviews of the prehospital trauma care scenario, including identifying the unmet prehospital needs. This might include understanding the proportion of trauma-related deaths that occur in the prehospital setting and understanding the de facto prehospital transport system for severely ill and injured persons. Such reviews might reasonably also address non-traumatic emergency care needs.
- Alternative arrangements should be created for prehospital care in areas where formal EMS systems are not possible or practical. Governments should identify ways in which to build on existing, albeit informal de facto systems and harness community resources, such as by identifying high-yield groups of the lay public for basic first aid training. Such programs should be carefully evaluated as to their cost and effectiveness before being scaled-up or converted to a formal EMS system.
- Governments should explore the possibility of establishing formal EMS in high yield areas, such as in urban areas and along major inter-urban roadways. Such exploration should emphasize cost considerations, given the likely high cost of establishing such systems.
In locations where there is formal EMS, governments should establish a monitoring agency to assure and promote minimum standards for training, equipment, infrastructure, and communication so as to assure delivery of prompt, quality, and equitable prehospital care. This agency should have mandate to regulate individual ambulance services, both private and governmental, to prevent unnecessary duplication of services and to assure adequate coordination among the services and between the services and other components of the emergency response system (e.g. fire, police, etc).
The WHO’s Prehospital Trauma Care Systems should be used as a basis for developing all of the above. Systems that are developed should be locally sustainable and should fit with local culture, health care systems, and resources. Care should be taken not to follow high-income models, unless these really fit a given environment and its resources. Systems that are built should be available to all who need them without regard of ability to pay. This does not obviate the need for cost recovery eventually; but such cost recovery should not prevent the provision of emergency care.
Facility based trauma care
Governments should establish the Guidelines for Essential Trauma Care (collaboratively developed by the WHO and the International Association for the Surgery of Trauma and Surgical Intensive Care – IATSIC) as a basis for facility-based trauma care in the country, including hospitals and clinics that provide care to the injured.
Essential trauma care services should be provided to all who need them in a timely fashion without regard to ability to pay. This does not obviate the possible need for cost recovery, as appropriate, after essential services have been rendered. Such cost recovery should not prevent the provision of essential care.
These services and the related essential trauma care resource criteria could be promoted through several means, including:
The knowledge and skills delineated in the Guidelines for Essential Trauma Care should form the basis for core competencies in the curricula of schools of medicine, nursing, and other pertinent allied health disciplines and in continuing education (in-service) courses. Such continuing education courses should be promoted and assured for all practitioners regularly providing trauma care.
Quality improvement programs
Quality improvement (QI) programs offer a means to assure the actual provision of quality essential services. It is to be emphasized that essential means not just the physical presence of resources, but that these resources are used to provide necessary care to all who need them in a timely and appropriate fashion. QI offers a means to assure this. Depending on the level of the facility, this might include monitoring of the structure, process, and/or outcome of trauma care. For smaller facilities that handle trauma cases, it would be reasonable to incorporate trauma related elements into more general QI programs. For larger facilities with high trauma volumes, specific trauma related QI programs would be reasonable, such as monitoring of preventable deaths using autopsy findings. Whatever QI processes are utilized, they should address the entire system, including prehospital care and rehabilitation.
Team approach and organization of initial resuscitation
Assuring the organization of the initial resuscitation can improve the prompt delivery of essential care. This often implies several providers working together in a team fashion with pre-assigned duties and responsibilities. This applies both to large urban centers with many providers as well as to smaller rural facilities with limited human resources. Improving the organization of the initial resuscitation by such means is an avenue to assuring the implementation of the Guidelines for Essential Trauma Care.
Every health care system has some means of assuring and improving the provision of care at its facilities. The elements from the Guidelines for Essential Trauma Care should be incorporated into ongoing and new mechanisms for such review, especially for facilities with high trauma volumes.
Broader system considerations
The Guidelines for Essential Trauma Care are a means of promoting broader improvements in the health care system, including non-trauma care, such as surgical and other emergencies. It also should be linked with broader system issues, such as: surveillance; prevention; access; prehospital care; relations between facilities, including referral and reception; and reintegration of the injured person back into society. The Guidelines for Essential Trauma Care offer a means of assessment of the functioning of the broader health care system, for identification of weaknesses that could be strengthened in a cost-effective fashion.
Establishing affordable and sustainable improvements in care of the injured requires adequate, reliable, and timely information on injuries and related deaths. Improvements in systems for care of the injured need to be based on solid facts. Changes that are made need to be assessed so as to know which measures are effective, and hence should be continued and scaled-up, and which measures are ineffective, and hence should be modified or discontinued. Thus, all countries should have in place mechanisms for gathering the needed injury-related information, as a component of their broader health information systems. The WHO’s Injury Surveillance Guidelines should be used as a basis for assuring adequate information on injury to accurately guide injury-care policy.