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Injury is a leading cause of mortality, hospitalised morbidity and disability in New Zealand.[[1]] There are over 2,000 hospital admissions with major trauma in New Zealand per year, with a national incidence of 51 cases per 100,000.[[2]] The burden of trauma falls disproportionally on rural communities, with a doubling in rates of injury from large urban to rural areas.[[3]] Within New Zealand, there are three tiers of trauma provision, tertiary trauma centres, regional trauma hospitals and smaller rural hospitals, which would often be bypassed in the incidence of major trauma.[[2]]

Since the recognition by Cowley that a multidisciplinary team lead to better trauma outcomes, trauma systems have been a rapidly developing and expanding field.[[4]] Across New Zealand, there are four major trauma networks which come under the governance of the National Trauma Network.[[3]] Many hospitals now have multidisciplinary trauma teams and a trauma call system in place, now with trauma call data being reported by the National Trauma Registry.[[3]] The goal of trauma teams is to ensure the early mobilisation and involvement of experienced medical staff, thereby leading to improved patient outcome.[[5]] Evidence suggests that patients with moderate–severe injuries (injury severity score, ISS >12) have a significantly better outcome when trauma teams are involved, rather than when being treated on a service-by-service basis.[[6]] Other benefits include improvement in triage time, reduced mean resuscitation time, and overall trend towards lower mortality and morbidity rates in patients with severe head injury.[[5,7,8]] In New Zealand specifically, trauma team activation has been shown to make time to CT scan on average twice as fast.[[3]] A trauma team approach allows for coordinated distribution of several tasks to be completed simultaneously.[[9]]

The composition of this team, however, is less well defined.[[5]] A large variation has been noted in a number of previous studies. Egberink et a.l found the number of trauma team members varied from 3 to 16 professionals when a nationwide survey of Dutch Emergency Departments was conducted.[[10]] This study refers to a trauma team as a multidisciplinary team that attends for the initial management of a trauma patient in the emergency department (ED), and is not referring to the presence of an in-patient admitting trauma service. The composition of trauma teams across New Zealand is not well known.

This study aims to investigate the availability and composition of trauma teams in current practice in New Zealand across all levels of trauma care. Trauma call criteria and the role of anaesthetists in trauma care will also be investigated.

Methods

Study population

A structured online questionnaire was distributed to all New Zealand hospitals that have the potential to manage major trauma patients. The survey responses were collected between 11 November–15 December 2021. The Ministry of Health list of public hospitals in New Zealand was used to identify eligible hospitals.[[11s]] A total of 84 hospitals were listed. Hospitals that did not have an ED (e.g., aged care, urgent care and psychiatric facilities) were excluded. Remaining were a total of 32 hospitals which could potentially receive and provide treatment for major trauma patients (see Figure 1).

Figure 1: Flowchart of survey distribution and return.

Survey design

The survey questionnaire was based on a literature review and tailored to the New Zealand context. The questionnaire developed and evaluated for content and readability by the Northland District Health Board trauma service, consisting of a trauma surgeon, registrars from both surgery and anaesthesia, as well as the trauma nurse specialist.

The survey consisted of two streams of questions: those who identified as having a trauma team and those who did not (Figure 2). If the respondents’ facility utilised a trauma team, the survey consisted of 22 questions using multiple choice, checkbox, free text and file attachment formats. These questions included trauma team members, activation criteria and activation methods. Those without a trauma team completed 11 questions consisting of multiple choice, checkbox and free text. Included were reasons why no trauma team is available, the perceived benefits to patients and the health service of trauma teams. Both groups were asked about the current role of anaesthetists in their facility and the perceived benefits or disadvantages of anaesthetist involvement in trauma. The specialty of the attending clinician was recorded corresponding to the department within the hospital they were representing. For example, an anaesthetist who was working in the ICU was recorded as “ICU”, and a rural medicine specialist working in a senior medical role in the emergency department was recorded as “ED consultant”. It was outlined that responses would represent the normal in-hours team that would attend and further questions about changes that occurred after hours were included so to explore this aspect.

Survey distribution

The survey distribution consisted of modified Dillman’s technique without financial incentive. Follow up emails were sent weekly for the first two weeks then again at week five and seven.[[12]] Phone contact was made with the trauma nurse specialists of each hospital, and if not available, the most appropriate person to distribute the survey to was determined on this initial phone contact. The surveys were initially distributed to trauma nurse specialists, or to the appropriate individual as determined on a case-by-case basis. Specific instructions were included to direct the initial recipient to seek assistance, or to forward the survey onto the most appropriate clinician if they felt unable to accurately answer the survey questions. Researcher details were also provided if any clarification was required by the individual respondents. Only one response was recorded from each hospital, as multiple responses from one hospital would not be able to be analysed if conflicting information was provided. Although, rural classified hospitals may not be required to manage major trauma as they would often be bypassed, it was thought these hospitals would be included to assess whether any of these smaller institutions were using a trauma team approach.

Phone contact was utilised for initial introduction to the concept of the study and then also at week five for follow-up if not completed at this stage. The survey was distributed using the Survey Monkey™ online platform.

Figure 2: Survey pathways.

Data collection and statistical analysis

Data was aggregated using the Survey Monkey™ platform. Categorical data were described as number and percentage. Normally distributed data were described as mean and standard deviation (SD). Non-normally distributed data were described as median and Quartile 1 and Quartile 3 (Q1–Q3).

Ethics

Out of scope HDEC approval was granted 7 April 2022. Participation from respondents was completely voluntary without incentivisation.

Results

Participating hospitals and respondents

Twenty-eight of the 32 (88%) hospitals returned a completed survey (see Table 1). There was a large variation in the size of the hospitals ranging from 14 to 1,165 beds. Respondents included 53% (15/28) trauma nurse specialists, 32% (9/28) doctors (not trauma-specific), 10% (3/28) trauma-specific doctors, and 3% (1/28) nurses (not trauma-specific). Across the domains assessed, there was no significant differences between the regional and tertiary trauma hospitals and, therefore, there has not been separation of this data.

Ninety percent (19/21) of hospitals with trauma team availability participated in local trauma quality assurance such as trauma committee meetings and review. Only 9.5% (2/21) of responding hospitals had trauma-specific fellowships available; two in general surgery and one in orthopaedics.

Trauma team availability

Seventy-five percent (21/28) of hospitals indicated a trauma team was available and a trauma call system was in place. All regional and tertiary trauma hospitals had a trauma team and no rural hospitals with ≤52 beds had a trauma team; therefore, all trauma team data are referring to regional and tertiary trauma hospitals. The number of trauma team activations varied, with 33% having <50 activations per annum, 20% having 50–100 activations, 10% having 100–200 activations, 33% with >200 activations, and 4% being unsure of the total number. All responding hospitals that had a trauma team provided this service continuously, independent of time of day or the day of the week. All hospitals had trauma call activation by either pre-hospital notification information and/or at triage. Thirty-eight percent (8/21) also had provisions for activation later once assessed in the ED.

Notification to the trauma team most commonly occurred via a specific trauma pager (14%) while other contact methods included regular pager system (10%), loudspeaker announcement (5%), mobile phone contact (10%), with the remainder (61%) employing a combination of pager and mobile phone contact.

Trauma team composition

The number of trauma team members ranged from 6–17, with a median of 10 (8.5–11.5). This includes a median number of 5 (4–6) medical members of the team and median of 5 (2.5–6) nursing/allied health members. These figures were similar when comparing tertiary hospitals to regionals trauma hospitals with the medians being 11 (9.5–11.5) and 10 (8–11.5). Table 2 outlines the specialities and seniority levels of members. Seventy-six percent (16/21) of hospitals had their trauma team change after hours with the majority comprising of more junior staff (75%; 12/16).

Role allocation within the trauma team

The consultant/fellow ED doctor was allocated as the team leader in 96% (20/21) of cases, with the other team leader being an emergency registrar under direct supervision of a consultant. The role of airway doctor was shared between the specialties of anaesthesia (57%), ICU (38%) and ED (4%). Assessment of breathing and circulation status was done mostly by an emergency registrar (8/21) or general surgical registrar (6/21). Procedures (such as chest drain insertion) was completed by a general surgical doctor in (7/21), an ED doctor in (6/21), and an ICU doctor in (3/21). These allocations were flexible in 96% of hospitals depending on patient and/or staffing requirements.

Trauma call criteria

Trauma call activation criteria in all respondents encompassed a combination of physiological criteria, injury pattern and injury mechanism. Across all hospitals GCS, heart rate, blood pressure and respiratory rate were universally used as activation criteria although specific cut-offs varied. Thirty-eight percent (8/21) used mandatory activation based on pre-hospital notification if classified as a status 1 or 2 patient. One third (7/21) had a two-tiered response with different teams attending with the majority using a single response to all trauma calls. Seventy-six percent (16/21) mandated a trauma call if the patient met any physiological and injury pattern criteria with discretionary call available based on mechanism of injury criteria. Nineteen percent had separate criteria for obstetrics, and 21% had paediatric criteria, excluding specific paediatric or adult only hospitals. Forty-eight percent had trauma call activation criteria if multiple casualties were expected; however, there was variation from two to six patients and 24% did not specify a number. It was not elucidated if responding hospitals had separate mass casualty procedures.

View Tables 1 –3.

Reasons for lack of trauma team

In the hospitals that did not have a trauma team 86% (6/7) identified staff availability as the major reason why a trauma team is not present. Other identified reasons included, too close to major trauma centre (2/7) and too few trauma patients (2/7). Just over half (57%) recognised that the formation of a trauma team at their facility may positively impact patient outcomes, and 57% also identified potential benefits for the centre at which they work if there were not the barriers as mentioned earlier with workforce issues.

Anaesthesia department involvement in trauma teams

Of the 21 responding hospitals with a trauma team system 62% (13/21) had involvement of a member of the anaesthesia department in the form of consultant, registrar or both responding to a trauma call. Large tertiary hospitals in the upper North Island did not include anaesthesia, but the smaller hospitals and South Island trauma hospitals incorporate an anaesthesia member into their teams. Furthermore, 50% (14/28) of respondents felt anaesthesia was best to manage airway in major trauma, and 79% (22/28) felt anaesthetists possess skills beneficial in the management of major trauma. Eighty-two percent (23/28) of respondents agreed that anaesthetists would probably or definitely add value to initial care of major trauma patients. Those that did not include anaesthesia in their trauma teams all indicated they would be involved if specific intervention was required.

Discussion

This study has shown that the use of trauma teams is common in New Zealand hospitals, with all regional and tertiary trauma centres having a trauma team response process, suggesting the majority of patients suffering major trauma are received by a trauma team. There was a wide variation in team composition, trauma call activation criteria and anaesthetic involvement.

An organised trauma team present at the time of arrival of a major trauma patient to the ED is known to have a positive impact on patient care.[[9]] The number of members within this trauma team varied significantly across the country, similarly to the international experience.[[10]] The median number of members being 10 is in line with a national study from the Netherlands.[[10]] Trends in the research however suggest the ideal number is less than this, citing a number of five to eight as the ideal number for adequate skill mix without compromising team leader oversight.[[13]] Across New Zealand, only 23% (5/21) of trauma teams fell within the recommended team size, with the majority of teams being larger. This has implication across New Zealand, as without a well-organised team there is the potential for team fragmentation, resulting in unnecessary procedures and the team leader losing oversight of the trauma resuscitation.[[13]]

The rate of trauma team utilisation is higher than many other countries where the rates vary from 21% to 98%.[[10,14–20]] This may reflect the well-developed trauma systems in place within New Zealand.[[21]] Future research may be able to provide comparisons with countries that have lower trauma team utilisation and major trauma outcomes to determine potential benefit to this high rate.

Smaller rural hospitals (≤52 beds) were unable to utilise a multidisciplinary approach to trauma care due to restrictions related to staff availability. These hospitals would generally be staffed by rural medicine specialists, and it is unlikely there would be any other medical specialties available to form a multidisciplinary trauma team. A formal trauma team response would also generally be unnecessary, as they are preferentially bypassed by major trauma patients if clinical condition allows. It is, however, reassuring of substantial clinician recognition of the benefits of such an approach to both the patient and institution.

Although there were large variations in team member numbers across New Zealand, there were a number of clear trends in roles allocated during trauma resuscitation. Geographical trends showed tertiary hospitals in the more northern regions utilising ICU more so than anaesthesia. The reasons for this are likely due to local availability of specialities to attend trauma calls. However, these roles were flexible. This may be good to overcome shortfalls however if team members are required to work outside their predetermined roles there is the potential for this to lead to non-optimal outcomes.[[22]] There is not clear evidence that the inclusion of intensive care or anaesthesia members in the team is beneficial over another however this may be an area of future study particularly regarding effectiveness of airway management and transit time to theatre or ICU. It may be also important to recognise the significant cross over between these specialties that still exists within New Zealand, which may limit the ability to conduct this investigation.

All hospitals that indicated a trauma team present had coverage 24 hours per day, seven days a week. However, the composition after hours changed in 76%, with the main change being a more junior team. Subsequently a more junior team with less experience dealing with major trauma may be unsure of their roles and responsibilities. This, however, is similar to the international experience with Australian studies demonstrating a rate of 74%.[[15]]

Hospitals with trauma teams utilised a criterion which incorporated aspects of physiological parameters and injury patterns for mandatory trauma call activation and discretionary calls based on injury mechanism. Table 3 outlines the specific criteria that was used by the responding hospitals. When comparing the criteria across New Zealand, there were many minor differences which has the potential to cause confusion. Specific examples include some criteria stating reduced GCS as a physiological parameter for a trauma call while others required specific GCS <14, <13, <12 or <9. Some even had specific time frames that this drop in GCS was required to be longer than five minutes. Similar trends were noted in the heart rate and respiratory rate requirements, with numbers for tachycardia and bradycardia to trigger a trauma call different across sites. There was, however, some standardisation across one of the trauma networks. There may be an argument that greater standardisation across trauma networks may improve familiarity with trauma call requirements. This may be particularly pertinent to those that rotate between hospitals, namely training registrars and there is evidence that standardisation within healthcare and specifically trauma systems can improve patient outcomes.[[23,24]] Although trauma team members may be required to be tailored to availability at certain hospitals, trauma call criteria is an area where there is potential for standardisation of practice.

Within the international literature, there is a trend towards utilisation of a two-tiered trauma call system. The reasons for this include avoiding a “cry wolf” situation where teams become fatigued from frequent calls and responses.[[25]] With a single-tiered system, there appears to be an increased risk of under triage, which Thoresen et al. determined translated to a significant increase in mortality within a Norwegian trauma system.[[26]] A 2–3x over-call rate is thought to be an acceptable level to prevent under call yet not cause significant team fatigue.[[27]] Trends across New Zealand demonstrate that 66% (14/21) trauma call response is a single-tiered response, meaning the same team attends for all trauma call. A two-tiered system could be explored and implemented within New Zealand with the potential benefits to decrease overcall rates, as well as reducing under triage, improving healthcare resource utilisation with potential for cost benefits.[[15,26]] Further research into the rates of over-call and under-call of trauma calls in the New Zealand context would be beneficial. During the composition of this study a national best practice critical bleeding bundle of care was being rolled out nationally, including a code crimson protocol.[[28]] The introduction of “code crimson”, which is a rapid transfer protocol for the critically bleeding patient has the potential to increase the number of tiered trauma call responses, depending on the current team that attends at the particular hospital.

Across the literature the involvement of anaesthesia appears to have regional variation, a variation which is seen across New Zealand.[[10,15]] Although the Australian and New Zealand College of Anaesthetists stops short of making recommendations about the attendance of anaesthetists in trauma teams, attendance as part of a trauma team is a requirement of training.[[29]] The Royal College of Anaesthetists, United Kingdom, however, mandates that an anaesthetist should be present as part of the team receiving major trauma patients.[[30]] This is something for consideration within the New Zealand context. As mentioned previously, it is not suggested that the inclusion of anaesthetists will directly improve patient outcomes but, importantly, that those who are involved in the management of trauma should have adequate exposure to volume of practice to maintain skills and knowledge. This could be by direct involvement in trauma team management of patients or other training methods.

This study is limited by survey respondent selection issues and respondent accuracy which was unable to be confirmed. However, the overall response rate was high and the majority of respondents were experts in trauma.

Conclusions

Trauma teams in New Zealand are common with the majority of major trauma patients treated by a trauma team. Hospitals that routinely receive major trauma patients have trauma teams and non-trauma hospitals do not. There is a wide variation in the number of members included in trauma teams as well as the trauma call criteria utilised. Anaesthesia departments are involved in over half of trauma teams, with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

View Appendices.

Summary

Abstract

Aim

Improved survival of trauma patients has been shown when a multidisciplinary trauma team is available. The aim of this study is to investigate the composition of trauma teams, trauma call criteria and the role of anaesthetists in trauma care across New Zealand.

Method

A survey was distributed using the modified Dillman’s technique. Data was collected and aggregated using an online platform. The survey consisted of two streams of questions depending on trauma team availability. Trauma nurse specialists were the first contact point and if not available, direct contact with the hospital was made for completion of the survey.

Results

Seventy-five percent of hospitals had a trauma team and trauma call system and correlated to size of the hospital. The number of trauma team members ranged from six to 17, with a median of 10. Trauma call activation criteria encompassed physiological criteria, injury pattern and injury mechanism criteria. Physiological criterial of GCS, heart rate, blood pressure and respiratory rate were universally used. Sixty-two percent of trauma teams had involvement of anaesthetists.

Conclusion

Trauma teams in New Zealand are common in regional and tertiary trauma hospitals. There is a wide variation in member numbers and criteria to trigger a trauma call. Anaesthetist involvement was in over half of trauma teams with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

Author Information

Dr Rohan Lynham BMBS, BHlthSc (Paramedic), EMCert: Anaesthesia Registrar, Auckland City Hospital, Auckland District Health Board, New Zealand. Dr Matthew McGuinness MBChB, MHSc: General Surgery Registrar, Invercargill Hospital, Southland District Health Board; Honorary Academic, The University of Auckland, New Zealand. Mr Christopher Harmston MBChB, FRCS(Eng), FRACS: Consultant General and Colorectal Surgeon, Northland District Health Board, Associate Professor, The University of Auckland, New Zealand.

Acknowledgements

We would like to thank the health professionals who completed the survey. Funding: Survey monkey™ platform was funded by Northern Regional Trauma Network.

Correspondence

Dr Rohan Lynham: c/- Anaesthesia department, Auckland City Hospital, 2 Park Road, Grafton, Auckland. Ph.: +649-367 0000

Correspondence Email

rlynham@outlook.com.au

Competing Interests

Nil.

1) Curtis K, Caldwell E, Delprado A, Munroe B. Traumatic injury in Australia and New Zealand. Australas Emerg Nurs J. 2012;15(1):45-54.

2) Network NT. New Zealand Trauma Registry and National Trauma Network Annual Report 2020/2021. New Zealand 2021.

3) Network NT. New Zealand Trauma Registry and National Trauma Network Annual Report 2019/2020. New Zealannd 2020.

4) Cowley RA. Trauma center. A new concept for the delivery of critical care. The Journal of the Medical Society of New Jersey. 1977;74(11):979-87.

5) Tiel Groenestege-Kreb D, van Maarseveen O, Leenen L, Howell SJ. Trauma team. BJA: British Journal of Anaesthesia. 2014;113(2):258-65.

6) Petrie D, Lane P, Stewart TC. An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. Journal of Trauma and Acute Care Surgery. 1996;41(5):870-5.

7) Lubbert PH, Kaasschieter EG, Hoorntje LE, Leenen LP. Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a level 1 trauma center. Journal of Trauma and Acute Care Surgery. 2009;67(6):1412-20.

8) Phillips J. Enhanced trauma program commitment at a level I trauma center: effect on the process and outcome of care. Archives of Surgery. 2003;138(8):838-43.

9) Driscoll P, Vincent CA. Variation in trauma resuscitation and its effect on patient outcome. Injury. 1992;23(2):111-5.

10) Egberink RE, Otten HJ, MJ IJ, van Vugt AB, Doggen CJ. Trauma team activation varies across Dutch emergency departments: a national survey. Scand J Trauma Resusc Emerg Med. 2015;23:100.

11) Health Mo. Certified list of public hosptials New Zealand Government 2022 [Available from: https://www.health.govt.nz/your-health/certified-providers/public-hospital.

12) Dillman DA. Mail and telephone surveys: The total design method: Wiley New York; 1978.

13) Adedeji OA, Driscoll PA. The trauma team--a system of initial trauma care. Postgraduate medical journal. 1996;72(852):587-93.

14) Kaplan LJ, Santora TA, Blank-Reid CA, Trooskin SZ. Improved emergency department efficiency with a three-tier trauma triage system. Injury. 1997;28(7):449-53.

15) Wong K, Petchell J. Trauma teams in Australia: a national survey. ANZ journal of surgery. 2003;73(10):819-25.

16) Larsen KT, Uleberg O, Skogvoll E. Differences in trauma team activation criteria among Norwegian hospitals. Scandinavian journal of trauma, resuscitation and emergency medicine. 2010;18(1):1-10.

17) Hornsby J, Quasim T, Dignon N, Puxty A. Provision of trauma teams in Scotland: a national survey. Emergency Medicine Journal. 2010;27(3):191-3.

18) Kazemi A, Nayeem N. The existence and composition of trauma teams in the UK. Injury. 1997;28(2):119-21.

19) Slagel SA, Skiendzielewski JJ, Martyak GG, Brotman S. Emergency medicine and surgery resident roles on the trauma team: a difference of opinion. Annals of emergency medicine. 1986;15(1):28-32.

20) Belhumeur V, Malo C, Nadeau A, Hegg-Deloye S, Gagné A-J, Émond M. Trauma team leaders in Canada: A national survey. Trauma. 2020;22(2):126-32.

21) Civil I, Twaddle B. Trauma care systems in New Zealand. Injury. 2003;34(9):740-4.

22) Lomas G, Goodall O. Trauma teams vs non-trauma teams. Accident and emergency nursing. 1994;2(4):205-10.

23) Dehli T, Uleberg O, Wisborg T. Trauma team activation - common rules, common gain. Acta Anaesthesiol Scand. 2018;62(2):144-6.

24) Sakran JV, Jehan F, Joseph B. Trauma Systems: Standardization and Regionalization of Care Improve Quality of Care. Current Trauma Reports. 2018;4(1):39-47.

25) Rehn M, Lossius HM, Tjosevik KE, Vetrhus M, Østebø O, Eken T, et al. Efficacy of a two-tiered trauma team activation protocol in a Norwegian trauma centre. Br J Surg. 2012;99(2):199-208.

26) Thorsen K, Narvestad JK, Tjosevik KE, Larsen JW, Søreide K. Changing from a two-tiered to a one-tiered trauma team activation protocol: a before-after observational cohort study investigating the clinical impact of undertriage. Eur J Trauma Emerg Surg. 2021.

27) Narvestad J, Tjosevik K, Larsen J, Søreide K. Changing from a two-tiered to a one-tiered trauma team activation protocol: a before–after observational cohort study investigating the clinical impact of undertriage. European Journal of Trauma and Emergency Surgery. 2021:1-9.

28) Network NT. A national best-practice critical bleeding bundle of care with associated guidance and massive transfusion protocol. National Trauma Network and the Health Quality & Safety Commission; 2020.

29) Anaesthetists AaNZCo. Anaesthesia training program curriculum Melbourne ANZCA; 2020 [Available from: https://www.anzca.edu.au/resources/all-handbooks-and-curriculums/anzca-anaesthesia-training-program-curriculum.

30) RCOA. Guidelines for the Provision of Anaesthesia Services (GPAS).

31) Guidelines for the Provision of Anaesthesia Services for Trauma and Orthopaedic Surgery 2021 United Kingdom: Royal College of Anaesthetists; 2021 [Available from: https://www.rcoa.ac.uk/sites/default/files/documents/2021-03/GPAS-2021-16-TRAUMA.pdf].

32) Baker SP, o'Neill B, Haddon Jr W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. Journal of Trauma and Acute Care Surgery. 1974;14(3):187-96.

For the PDF of this article,
contact nzmj@nzma.org.nz

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Injury is a leading cause of mortality, hospitalised morbidity and disability in New Zealand.[[1]] There are over 2,000 hospital admissions with major trauma in New Zealand per year, with a national incidence of 51 cases per 100,000.[[2]] The burden of trauma falls disproportionally on rural communities, with a doubling in rates of injury from large urban to rural areas.[[3]] Within New Zealand, there are three tiers of trauma provision, tertiary trauma centres, regional trauma hospitals and smaller rural hospitals, which would often be bypassed in the incidence of major trauma.[[2]]

Since the recognition by Cowley that a multidisciplinary team lead to better trauma outcomes, trauma systems have been a rapidly developing and expanding field.[[4]] Across New Zealand, there are four major trauma networks which come under the governance of the National Trauma Network.[[3]] Many hospitals now have multidisciplinary trauma teams and a trauma call system in place, now with trauma call data being reported by the National Trauma Registry.[[3]] The goal of trauma teams is to ensure the early mobilisation and involvement of experienced medical staff, thereby leading to improved patient outcome.[[5]] Evidence suggests that patients with moderate–severe injuries (injury severity score, ISS >12) have a significantly better outcome when trauma teams are involved, rather than when being treated on a service-by-service basis.[[6]] Other benefits include improvement in triage time, reduced mean resuscitation time, and overall trend towards lower mortality and morbidity rates in patients with severe head injury.[[5,7,8]] In New Zealand specifically, trauma team activation has been shown to make time to CT scan on average twice as fast.[[3]] A trauma team approach allows for coordinated distribution of several tasks to be completed simultaneously.[[9]]

The composition of this team, however, is less well defined.[[5]] A large variation has been noted in a number of previous studies. Egberink et a.l found the number of trauma team members varied from 3 to 16 professionals when a nationwide survey of Dutch Emergency Departments was conducted.[[10]] This study refers to a trauma team as a multidisciplinary team that attends for the initial management of a trauma patient in the emergency department (ED), and is not referring to the presence of an in-patient admitting trauma service. The composition of trauma teams across New Zealand is not well known.

This study aims to investigate the availability and composition of trauma teams in current practice in New Zealand across all levels of trauma care. Trauma call criteria and the role of anaesthetists in trauma care will also be investigated.

Methods

Study population

A structured online questionnaire was distributed to all New Zealand hospitals that have the potential to manage major trauma patients. The survey responses were collected between 11 November–15 December 2021. The Ministry of Health list of public hospitals in New Zealand was used to identify eligible hospitals.[[11s]] A total of 84 hospitals were listed. Hospitals that did not have an ED (e.g., aged care, urgent care and psychiatric facilities) were excluded. Remaining were a total of 32 hospitals which could potentially receive and provide treatment for major trauma patients (see Figure 1).

Figure 1: Flowchart of survey distribution and return.

Survey design

The survey questionnaire was based on a literature review and tailored to the New Zealand context. The questionnaire developed and evaluated for content and readability by the Northland District Health Board trauma service, consisting of a trauma surgeon, registrars from both surgery and anaesthesia, as well as the trauma nurse specialist.

The survey consisted of two streams of questions: those who identified as having a trauma team and those who did not (Figure 2). If the respondents’ facility utilised a trauma team, the survey consisted of 22 questions using multiple choice, checkbox, free text and file attachment formats. These questions included trauma team members, activation criteria and activation methods. Those without a trauma team completed 11 questions consisting of multiple choice, checkbox and free text. Included were reasons why no trauma team is available, the perceived benefits to patients and the health service of trauma teams. Both groups were asked about the current role of anaesthetists in their facility and the perceived benefits or disadvantages of anaesthetist involvement in trauma. The specialty of the attending clinician was recorded corresponding to the department within the hospital they were representing. For example, an anaesthetist who was working in the ICU was recorded as “ICU”, and a rural medicine specialist working in a senior medical role in the emergency department was recorded as “ED consultant”. It was outlined that responses would represent the normal in-hours team that would attend and further questions about changes that occurred after hours were included so to explore this aspect.

Survey distribution

The survey distribution consisted of modified Dillman’s technique without financial incentive. Follow up emails were sent weekly for the first two weeks then again at week five and seven.[[12]] Phone contact was made with the trauma nurse specialists of each hospital, and if not available, the most appropriate person to distribute the survey to was determined on this initial phone contact. The surveys were initially distributed to trauma nurse specialists, or to the appropriate individual as determined on a case-by-case basis. Specific instructions were included to direct the initial recipient to seek assistance, or to forward the survey onto the most appropriate clinician if they felt unable to accurately answer the survey questions. Researcher details were also provided if any clarification was required by the individual respondents. Only one response was recorded from each hospital, as multiple responses from one hospital would not be able to be analysed if conflicting information was provided. Although, rural classified hospitals may not be required to manage major trauma as they would often be bypassed, it was thought these hospitals would be included to assess whether any of these smaller institutions were using a trauma team approach.

Phone contact was utilised for initial introduction to the concept of the study and then also at week five for follow-up if not completed at this stage. The survey was distributed using the Survey Monkey™ online platform.

Figure 2: Survey pathways.

Data collection and statistical analysis

Data was aggregated using the Survey Monkey™ platform. Categorical data were described as number and percentage. Normally distributed data were described as mean and standard deviation (SD). Non-normally distributed data were described as median and Quartile 1 and Quartile 3 (Q1–Q3).

Ethics

Out of scope HDEC approval was granted 7 April 2022. Participation from respondents was completely voluntary without incentivisation.

Results

Participating hospitals and respondents

Twenty-eight of the 32 (88%) hospitals returned a completed survey (see Table 1). There was a large variation in the size of the hospitals ranging from 14 to 1,165 beds. Respondents included 53% (15/28) trauma nurse specialists, 32% (9/28) doctors (not trauma-specific), 10% (3/28) trauma-specific doctors, and 3% (1/28) nurses (not trauma-specific). Across the domains assessed, there was no significant differences between the regional and tertiary trauma hospitals and, therefore, there has not been separation of this data.

Ninety percent (19/21) of hospitals with trauma team availability participated in local trauma quality assurance such as trauma committee meetings and review. Only 9.5% (2/21) of responding hospitals had trauma-specific fellowships available; two in general surgery and one in orthopaedics.

Trauma team availability

Seventy-five percent (21/28) of hospitals indicated a trauma team was available and a trauma call system was in place. All regional and tertiary trauma hospitals had a trauma team and no rural hospitals with ≤52 beds had a trauma team; therefore, all trauma team data are referring to regional and tertiary trauma hospitals. The number of trauma team activations varied, with 33% having <50 activations per annum, 20% having 50–100 activations, 10% having 100–200 activations, 33% with >200 activations, and 4% being unsure of the total number. All responding hospitals that had a trauma team provided this service continuously, independent of time of day or the day of the week. All hospitals had trauma call activation by either pre-hospital notification information and/or at triage. Thirty-eight percent (8/21) also had provisions for activation later once assessed in the ED.

Notification to the trauma team most commonly occurred via a specific trauma pager (14%) while other contact methods included regular pager system (10%), loudspeaker announcement (5%), mobile phone contact (10%), with the remainder (61%) employing a combination of pager and mobile phone contact.

Trauma team composition

The number of trauma team members ranged from 6–17, with a median of 10 (8.5–11.5). This includes a median number of 5 (4–6) medical members of the team and median of 5 (2.5–6) nursing/allied health members. These figures were similar when comparing tertiary hospitals to regionals trauma hospitals with the medians being 11 (9.5–11.5) and 10 (8–11.5). Table 2 outlines the specialities and seniority levels of members. Seventy-six percent (16/21) of hospitals had their trauma team change after hours with the majority comprising of more junior staff (75%; 12/16).

Role allocation within the trauma team

The consultant/fellow ED doctor was allocated as the team leader in 96% (20/21) of cases, with the other team leader being an emergency registrar under direct supervision of a consultant. The role of airway doctor was shared between the specialties of anaesthesia (57%), ICU (38%) and ED (4%). Assessment of breathing and circulation status was done mostly by an emergency registrar (8/21) or general surgical registrar (6/21). Procedures (such as chest drain insertion) was completed by a general surgical doctor in (7/21), an ED doctor in (6/21), and an ICU doctor in (3/21). These allocations were flexible in 96% of hospitals depending on patient and/or staffing requirements.

Trauma call criteria

Trauma call activation criteria in all respondents encompassed a combination of physiological criteria, injury pattern and injury mechanism. Across all hospitals GCS, heart rate, blood pressure and respiratory rate were universally used as activation criteria although specific cut-offs varied. Thirty-eight percent (8/21) used mandatory activation based on pre-hospital notification if classified as a status 1 or 2 patient. One third (7/21) had a two-tiered response with different teams attending with the majority using a single response to all trauma calls. Seventy-six percent (16/21) mandated a trauma call if the patient met any physiological and injury pattern criteria with discretionary call available based on mechanism of injury criteria. Nineteen percent had separate criteria for obstetrics, and 21% had paediatric criteria, excluding specific paediatric or adult only hospitals. Forty-eight percent had trauma call activation criteria if multiple casualties were expected; however, there was variation from two to six patients and 24% did not specify a number. It was not elucidated if responding hospitals had separate mass casualty procedures.

View Tables 1 –3.

Reasons for lack of trauma team

In the hospitals that did not have a trauma team 86% (6/7) identified staff availability as the major reason why a trauma team is not present. Other identified reasons included, too close to major trauma centre (2/7) and too few trauma patients (2/7). Just over half (57%) recognised that the formation of a trauma team at their facility may positively impact patient outcomes, and 57% also identified potential benefits for the centre at which they work if there were not the barriers as mentioned earlier with workforce issues.

Anaesthesia department involvement in trauma teams

Of the 21 responding hospitals with a trauma team system 62% (13/21) had involvement of a member of the anaesthesia department in the form of consultant, registrar or both responding to a trauma call. Large tertiary hospitals in the upper North Island did not include anaesthesia, but the smaller hospitals and South Island trauma hospitals incorporate an anaesthesia member into their teams. Furthermore, 50% (14/28) of respondents felt anaesthesia was best to manage airway in major trauma, and 79% (22/28) felt anaesthetists possess skills beneficial in the management of major trauma. Eighty-two percent (23/28) of respondents agreed that anaesthetists would probably or definitely add value to initial care of major trauma patients. Those that did not include anaesthesia in their trauma teams all indicated they would be involved if specific intervention was required.

Discussion

This study has shown that the use of trauma teams is common in New Zealand hospitals, with all regional and tertiary trauma centres having a trauma team response process, suggesting the majority of patients suffering major trauma are received by a trauma team. There was a wide variation in team composition, trauma call activation criteria and anaesthetic involvement.

An organised trauma team present at the time of arrival of a major trauma patient to the ED is known to have a positive impact on patient care.[[9]] The number of members within this trauma team varied significantly across the country, similarly to the international experience.[[10]] The median number of members being 10 is in line with a national study from the Netherlands.[[10]] Trends in the research however suggest the ideal number is less than this, citing a number of five to eight as the ideal number for adequate skill mix without compromising team leader oversight.[[13]] Across New Zealand, only 23% (5/21) of trauma teams fell within the recommended team size, with the majority of teams being larger. This has implication across New Zealand, as without a well-organised team there is the potential for team fragmentation, resulting in unnecessary procedures and the team leader losing oversight of the trauma resuscitation.[[13]]

The rate of trauma team utilisation is higher than many other countries where the rates vary from 21% to 98%.[[10,14–20]] This may reflect the well-developed trauma systems in place within New Zealand.[[21]] Future research may be able to provide comparisons with countries that have lower trauma team utilisation and major trauma outcomes to determine potential benefit to this high rate.

Smaller rural hospitals (≤52 beds) were unable to utilise a multidisciplinary approach to trauma care due to restrictions related to staff availability. These hospitals would generally be staffed by rural medicine specialists, and it is unlikely there would be any other medical specialties available to form a multidisciplinary trauma team. A formal trauma team response would also generally be unnecessary, as they are preferentially bypassed by major trauma patients if clinical condition allows. It is, however, reassuring of substantial clinician recognition of the benefits of such an approach to both the patient and institution.

Although there were large variations in team member numbers across New Zealand, there were a number of clear trends in roles allocated during trauma resuscitation. Geographical trends showed tertiary hospitals in the more northern regions utilising ICU more so than anaesthesia. The reasons for this are likely due to local availability of specialities to attend trauma calls. However, these roles were flexible. This may be good to overcome shortfalls however if team members are required to work outside their predetermined roles there is the potential for this to lead to non-optimal outcomes.[[22]] There is not clear evidence that the inclusion of intensive care or anaesthesia members in the team is beneficial over another however this may be an area of future study particularly regarding effectiveness of airway management and transit time to theatre or ICU. It may be also important to recognise the significant cross over between these specialties that still exists within New Zealand, which may limit the ability to conduct this investigation.

All hospitals that indicated a trauma team present had coverage 24 hours per day, seven days a week. However, the composition after hours changed in 76%, with the main change being a more junior team. Subsequently a more junior team with less experience dealing with major trauma may be unsure of their roles and responsibilities. This, however, is similar to the international experience with Australian studies demonstrating a rate of 74%.[[15]]

Hospitals with trauma teams utilised a criterion which incorporated aspects of physiological parameters and injury patterns for mandatory trauma call activation and discretionary calls based on injury mechanism. Table 3 outlines the specific criteria that was used by the responding hospitals. When comparing the criteria across New Zealand, there were many minor differences which has the potential to cause confusion. Specific examples include some criteria stating reduced GCS as a physiological parameter for a trauma call while others required specific GCS <14, <13, <12 or <9. Some even had specific time frames that this drop in GCS was required to be longer than five minutes. Similar trends were noted in the heart rate and respiratory rate requirements, with numbers for tachycardia and bradycardia to trigger a trauma call different across sites. There was, however, some standardisation across one of the trauma networks. There may be an argument that greater standardisation across trauma networks may improve familiarity with trauma call requirements. This may be particularly pertinent to those that rotate between hospitals, namely training registrars and there is evidence that standardisation within healthcare and specifically trauma systems can improve patient outcomes.[[23,24]] Although trauma team members may be required to be tailored to availability at certain hospitals, trauma call criteria is an area where there is potential for standardisation of practice.

Within the international literature, there is a trend towards utilisation of a two-tiered trauma call system. The reasons for this include avoiding a “cry wolf” situation where teams become fatigued from frequent calls and responses.[[25]] With a single-tiered system, there appears to be an increased risk of under triage, which Thoresen et al. determined translated to a significant increase in mortality within a Norwegian trauma system.[[26]] A 2–3x over-call rate is thought to be an acceptable level to prevent under call yet not cause significant team fatigue.[[27]] Trends across New Zealand demonstrate that 66% (14/21) trauma call response is a single-tiered response, meaning the same team attends for all trauma call. A two-tiered system could be explored and implemented within New Zealand with the potential benefits to decrease overcall rates, as well as reducing under triage, improving healthcare resource utilisation with potential for cost benefits.[[15,26]] Further research into the rates of over-call and under-call of trauma calls in the New Zealand context would be beneficial. During the composition of this study a national best practice critical bleeding bundle of care was being rolled out nationally, including a code crimson protocol.[[28]] The introduction of “code crimson”, which is a rapid transfer protocol for the critically bleeding patient has the potential to increase the number of tiered trauma call responses, depending on the current team that attends at the particular hospital.

Across the literature the involvement of anaesthesia appears to have regional variation, a variation which is seen across New Zealand.[[10,15]] Although the Australian and New Zealand College of Anaesthetists stops short of making recommendations about the attendance of anaesthetists in trauma teams, attendance as part of a trauma team is a requirement of training.[[29]] The Royal College of Anaesthetists, United Kingdom, however, mandates that an anaesthetist should be present as part of the team receiving major trauma patients.[[30]] This is something for consideration within the New Zealand context. As mentioned previously, it is not suggested that the inclusion of anaesthetists will directly improve patient outcomes but, importantly, that those who are involved in the management of trauma should have adequate exposure to volume of practice to maintain skills and knowledge. This could be by direct involvement in trauma team management of patients or other training methods.

This study is limited by survey respondent selection issues and respondent accuracy which was unable to be confirmed. However, the overall response rate was high and the majority of respondents were experts in trauma.

Conclusions

Trauma teams in New Zealand are common with the majority of major trauma patients treated by a trauma team. Hospitals that routinely receive major trauma patients have trauma teams and non-trauma hospitals do not. There is a wide variation in the number of members included in trauma teams as well as the trauma call criteria utilised. Anaesthesia departments are involved in over half of trauma teams, with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

View Appendices.

Summary

Abstract

Aim

Improved survival of trauma patients has been shown when a multidisciplinary trauma team is available. The aim of this study is to investigate the composition of trauma teams, trauma call criteria and the role of anaesthetists in trauma care across New Zealand.

Method

A survey was distributed using the modified Dillman’s technique. Data was collected and aggregated using an online platform. The survey consisted of two streams of questions depending on trauma team availability. Trauma nurse specialists were the first contact point and if not available, direct contact with the hospital was made for completion of the survey.

Results

Seventy-five percent of hospitals had a trauma team and trauma call system and correlated to size of the hospital. The number of trauma team members ranged from six to 17, with a median of 10. Trauma call activation criteria encompassed physiological criteria, injury pattern and injury mechanism criteria. Physiological criterial of GCS, heart rate, blood pressure and respiratory rate were universally used. Sixty-two percent of trauma teams had involvement of anaesthetists.

Conclusion

Trauma teams in New Zealand are common in regional and tertiary trauma hospitals. There is a wide variation in member numbers and criteria to trigger a trauma call. Anaesthetist involvement was in over half of trauma teams with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

Author Information

Dr Rohan Lynham BMBS, BHlthSc (Paramedic), EMCert: Anaesthesia Registrar, Auckland City Hospital, Auckland District Health Board, New Zealand. Dr Matthew McGuinness MBChB, MHSc: General Surgery Registrar, Invercargill Hospital, Southland District Health Board; Honorary Academic, The University of Auckland, New Zealand. Mr Christopher Harmston MBChB, FRCS(Eng), FRACS: Consultant General and Colorectal Surgeon, Northland District Health Board, Associate Professor, The University of Auckland, New Zealand.

Acknowledgements

We would like to thank the health professionals who completed the survey. Funding: Survey monkey™ platform was funded by Northern Regional Trauma Network.

Correspondence

Dr Rohan Lynham: c/- Anaesthesia department, Auckland City Hospital, 2 Park Road, Grafton, Auckland. Ph.: +649-367 0000

Correspondence Email

rlynham@outlook.com.au

Competing Interests

Nil.

1) Curtis K, Caldwell E, Delprado A, Munroe B. Traumatic injury in Australia and New Zealand. Australas Emerg Nurs J. 2012;15(1):45-54.

2) Network NT. New Zealand Trauma Registry and National Trauma Network Annual Report 2020/2021. New Zealand 2021.

3) Network NT. New Zealand Trauma Registry and National Trauma Network Annual Report 2019/2020. New Zealannd 2020.

4) Cowley RA. Trauma center. A new concept for the delivery of critical care. The Journal of the Medical Society of New Jersey. 1977;74(11):979-87.

5) Tiel Groenestege-Kreb D, van Maarseveen O, Leenen L, Howell SJ. Trauma team. BJA: British Journal of Anaesthesia. 2014;113(2):258-65.

6) Petrie D, Lane P, Stewart TC. An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. Journal of Trauma and Acute Care Surgery. 1996;41(5):870-5.

7) Lubbert PH, Kaasschieter EG, Hoorntje LE, Leenen LP. Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a level 1 trauma center. Journal of Trauma and Acute Care Surgery. 2009;67(6):1412-20.

8) Phillips J. Enhanced trauma program commitment at a level I trauma center: effect on the process and outcome of care. Archives of Surgery. 2003;138(8):838-43.

9) Driscoll P, Vincent CA. Variation in trauma resuscitation and its effect on patient outcome. Injury. 1992;23(2):111-5.

10) Egberink RE, Otten HJ, MJ IJ, van Vugt AB, Doggen CJ. Trauma team activation varies across Dutch emergency departments: a national survey. Scand J Trauma Resusc Emerg Med. 2015;23:100.

11) Health Mo. Certified list of public hosptials New Zealand Government 2022 [Available from: https://www.health.govt.nz/your-health/certified-providers/public-hospital.

12) Dillman DA. Mail and telephone surveys: The total design method: Wiley New York; 1978.

13) Adedeji OA, Driscoll PA. The trauma team--a system of initial trauma care. Postgraduate medical journal. 1996;72(852):587-93.

14) Kaplan LJ, Santora TA, Blank-Reid CA, Trooskin SZ. Improved emergency department efficiency with a three-tier trauma triage system. Injury. 1997;28(7):449-53.

15) Wong K, Petchell J. Trauma teams in Australia: a national survey. ANZ journal of surgery. 2003;73(10):819-25.

16) Larsen KT, Uleberg O, Skogvoll E. Differences in trauma team activation criteria among Norwegian hospitals. Scandinavian journal of trauma, resuscitation and emergency medicine. 2010;18(1):1-10.

17) Hornsby J, Quasim T, Dignon N, Puxty A. Provision of trauma teams in Scotland: a national survey. Emergency Medicine Journal. 2010;27(3):191-3.

18) Kazemi A, Nayeem N. The existence and composition of trauma teams in the UK. Injury. 1997;28(2):119-21.

19) Slagel SA, Skiendzielewski JJ, Martyak GG, Brotman S. Emergency medicine and surgery resident roles on the trauma team: a difference of opinion. Annals of emergency medicine. 1986;15(1):28-32.

20) Belhumeur V, Malo C, Nadeau A, Hegg-Deloye S, Gagné A-J, Émond M. Trauma team leaders in Canada: A national survey. Trauma. 2020;22(2):126-32.

21) Civil I, Twaddle B. Trauma care systems in New Zealand. Injury. 2003;34(9):740-4.

22) Lomas G, Goodall O. Trauma teams vs non-trauma teams. Accident and emergency nursing. 1994;2(4):205-10.

23) Dehli T, Uleberg O, Wisborg T. Trauma team activation - common rules, common gain. Acta Anaesthesiol Scand. 2018;62(2):144-6.

24) Sakran JV, Jehan F, Joseph B. Trauma Systems: Standardization and Regionalization of Care Improve Quality of Care. Current Trauma Reports. 2018;4(1):39-47.

25) Rehn M, Lossius HM, Tjosevik KE, Vetrhus M, Østebø O, Eken T, et al. Efficacy of a two-tiered trauma team activation protocol in a Norwegian trauma centre. Br J Surg. 2012;99(2):199-208.

26) Thorsen K, Narvestad JK, Tjosevik KE, Larsen JW, Søreide K. Changing from a two-tiered to a one-tiered trauma team activation protocol: a before-after observational cohort study investigating the clinical impact of undertriage. Eur J Trauma Emerg Surg. 2021.

27) Narvestad J, Tjosevik K, Larsen J, Søreide K. Changing from a two-tiered to a one-tiered trauma team activation protocol: a before–after observational cohort study investigating the clinical impact of undertriage. European Journal of Trauma and Emergency Surgery. 2021:1-9.

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29) Anaesthetists AaNZCo. Anaesthesia training program curriculum Melbourne ANZCA; 2020 [Available from: https://www.anzca.edu.au/resources/all-handbooks-and-curriculums/anzca-anaesthesia-training-program-curriculum.

30) RCOA. Guidelines for the Provision of Anaesthesia Services (GPAS).

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For the PDF of this article,
contact nzmj@nzma.org.nz

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Injury is a leading cause of mortality, hospitalised morbidity and disability in New Zealand.[[1]] There are over 2,000 hospital admissions with major trauma in New Zealand per year, with a national incidence of 51 cases per 100,000.[[2]] The burden of trauma falls disproportionally on rural communities, with a doubling in rates of injury from large urban to rural areas.[[3]] Within New Zealand, there are three tiers of trauma provision, tertiary trauma centres, regional trauma hospitals and smaller rural hospitals, which would often be bypassed in the incidence of major trauma.[[2]]

Since the recognition by Cowley that a multidisciplinary team lead to better trauma outcomes, trauma systems have been a rapidly developing and expanding field.[[4]] Across New Zealand, there are four major trauma networks which come under the governance of the National Trauma Network.[[3]] Many hospitals now have multidisciplinary trauma teams and a trauma call system in place, now with trauma call data being reported by the National Trauma Registry.[[3]] The goal of trauma teams is to ensure the early mobilisation and involvement of experienced medical staff, thereby leading to improved patient outcome.[[5]] Evidence suggests that patients with moderate–severe injuries (injury severity score, ISS >12) have a significantly better outcome when trauma teams are involved, rather than when being treated on a service-by-service basis.[[6]] Other benefits include improvement in triage time, reduced mean resuscitation time, and overall trend towards lower mortality and morbidity rates in patients with severe head injury.[[5,7,8]] In New Zealand specifically, trauma team activation has been shown to make time to CT scan on average twice as fast.[[3]] A trauma team approach allows for coordinated distribution of several tasks to be completed simultaneously.[[9]]

The composition of this team, however, is less well defined.[[5]] A large variation has been noted in a number of previous studies. Egberink et a.l found the number of trauma team members varied from 3 to 16 professionals when a nationwide survey of Dutch Emergency Departments was conducted.[[10]] This study refers to a trauma team as a multidisciplinary team that attends for the initial management of a trauma patient in the emergency department (ED), and is not referring to the presence of an in-patient admitting trauma service. The composition of trauma teams across New Zealand is not well known.

This study aims to investigate the availability and composition of trauma teams in current practice in New Zealand across all levels of trauma care. Trauma call criteria and the role of anaesthetists in trauma care will also be investigated.

Methods

Study population

A structured online questionnaire was distributed to all New Zealand hospitals that have the potential to manage major trauma patients. The survey responses were collected between 11 November–15 December 2021. The Ministry of Health list of public hospitals in New Zealand was used to identify eligible hospitals.[[11s]] A total of 84 hospitals were listed. Hospitals that did not have an ED (e.g., aged care, urgent care and psychiatric facilities) were excluded. Remaining were a total of 32 hospitals which could potentially receive and provide treatment for major trauma patients (see Figure 1).

Figure 1: Flowchart of survey distribution and return.

Survey design

The survey questionnaire was based on a literature review and tailored to the New Zealand context. The questionnaire developed and evaluated for content and readability by the Northland District Health Board trauma service, consisting of a trauma surgeon, registrars from both surgery and anaesthesia, as well as the trauma nurse specialist.

The survey consisted of two streams of questions: those who identified as having a trauma team and those who did not (Figure 2). If the respondents’ facility utilised a trauma team, the survey consisted of 22 questions using multiple choice, checkbox, free text and file attachment formats. These questions included trauma team members, activation criteria and activation methods. Those without a trauma team completed 11 questions consisting of multiple choice, checkbox and free text. Included were reasons why no trauma team is available, the perceived benefits to patients and the health service of trauma teams. Both groups were asked about the current role of anaesthetists in their facility and the perceived benefits or disadvantages of anaesthetist involvement in trauma. The specialty of the attending clinician was recorded corresponding to the department within the hospital they were representing. For example, an anaesthetist who was working in the ICU was recorded as “ICU”, and a rural medicine specialist working in a senior medical role in the emergency department was recorded as “ED consultant”. It was outlined that responses would represent the normal in-hours team that would attend and further questions about changes that occurred after hours were included so to explore this aspect.

Survey distribution

The survey distribution consisted of modified Dillman’s technique without financial incentive. Follow up emails were sent weekly for the first two weeks then again at week five and seven.[[12]] Phone contact was made with the trauma nurse specialists of each hospital, and if not available, the most appropriate person to distribute the survey to was determined on this initial phone contact. The surveys were initially distributed to trauma nurse specialists, or to the appropriate individual as determined on a case-by-case basis. Specific instructions were included to direct the initial recipient to seek assistance, or to forward the survey onto the most appropriate clinician if they felt unable to accurately answer the survey questions. Researcher details were also provided if any clarification was required by the individual respondents. Only one response was recorded from each hospital, as multiple responses from one hospital would not be able to be analysed if conflicting information was provided. Although, rural classified hospitals may not be required to manage major trauma as they would often be bypassed, it was thought these hospitals would be included to assess whether any of these smaller institutions were using a trauma team approach.

Phone contact was utilised for initial introduction to the concept of the study and then also at week five for follow-up if not completed at this stage. The survey was distributed using the Survey Monkey™ online platform.

Figure 2: Survey pathways.

Data collection and statistical analysis

Data was aggregated using the Survey Monkey™ platform. Categorical data were described as number and percentage. Normally distributed data were described as mean and standard deviation (SD). Non-normally distributed data were described as median and Quartile 1 and Quartile 3 (Q1–Q3).

Ethics

Out of scope HDEC approval was granted 7 April 2022. Participation from respondents was completely voluntary without incentivisation.

Results

Participating hospitals and respondents

Twenty-eight of the 32 (88%) hospitals returned a completed survey (see Table 1). There was a large variation in the size of the hospitals ranging from 14 to 1,165 beds. Respondents included 53% (15/28) trauma nurse specialists, 32% (9/28) doctors (not trauma-specific), 10% (3/28) trauma-specific doctors, and 3% (1/28) nurses (not trauma-specific). Across the domains assessed, there was no significant differences between the regional and tertiary trauma hospitals and, therefore, there has not been separation of this data.

Ninety percent (19/21) of hospitals with trauma team availability participated in local trauma quality assurance such as trauma committee meetings and review. Only 9.5% (2/21) of responding hospitals had trauma-specific fellowships available; two in general surgery and one in orthopaedics.

Trauma team availability

Seventy-five percent (21/28) of hospitals indicated a trauma team was available and a trauma call system was in place. All regional and tertiary trauma hospitals had a trauma team and no rural hospitals with ≤52 beds had a trauma team; therefore, all trauma team data are referring to regional and tertiary trauma hospitals. The number of trauma team activations varied, with 33% having <50 activations per annum, 20% having 50–100 activations, 10% having 100–200 activations, 33% with >200 activations, and 4% being unsure of the total number. All responding hospitals that had a trauma team provided this service continuously, independent of time of day or the day of the week. All hospitals had trauma call activation by either pre-hospital notification information and/or at triage. Thirty-eight percent (8/21) also had provisions for activation later once assessed in the ED.

Notification to the trauma team most commonly occurred via a specific trauma pager (14%) while other contact methods included regular pager system (10%), loudspeaker announcement (5%), mobile phone contact (10%), with the remainder (61%) employing a combination of pager and mobile phone contact.

Trauma team composition

The number of trauma team members ranged from 6–17, with a median of 10 (8.5–11.5). This includes a median number of 5 (4–6) medical members of the team and median of 5 (2.5–6) nursing/allied health members. These figures were similar when comparing tertiary hospitals to regionals trauma hospitals with the medians being 11 (9.5–11.5) and 10 (8–11.5). Table 2 outlines the specialities and seniority levels of members. Seventy-six percent (16/21) of hospitals had their trauma team change after hours with the majority comprising of more junior staff (75%; 12/16).

Role allocation within the trauma team

The consultant/fellow ED doctor was allocated as the team leader in 96% (20/21) of cases, with the other team leader being an emergency registrar under direct supervision of a consultant. The role of airway doctor was shared between the specialties of anaesthesia (57%), ICU (38%) and ED (4%). Assessment of breathing and circulation status was done mostly by an emergency registrar (8/21) or general surgical registrar (6/21). Procedures (such as chest drain insertion) was completed by a general surgical doctor in (7/21), an ED doctor in (6/21), and an ICU doctor in (3/21). These allocations were flexible in 96% of hospitals depending on patient and/or staffing requirements.

Trauma call criteria

Trauma call activation criteria in all respondents encompassed a combination of physiological criteria, injury pattern and injury mechanism. Across all hospitals GCS, heart rate, blood pressure and respiratory rate were universally used as activation criteria although specific cut-offs varied. Thirty-eight percent (8/21) used mandatory activation based on pre-hospital notification if classified as a status 1 or 2 patient. One third (7/21) had a two-tiered response with different teams attending with the majority using a single response to all trauma calls. Seventy-six percent (16/21) mandated a trauma call if the patient met any physiological and injury pattern criteria with discretionary call available based on mechanism of injury criteria. Nineteen percent had separate criteria for obstetrics, and 21% had paediatric criteria, excluding specific paediatric or adult only hospitals. Forty-eight percent had trauma call activation criteria if multiple casualties were expected; however, there was variation from two to six patients and 24% did not specify a number. It was not elucidated if responding hospitals had separate mass casualty procedures.

View Tables 1 –3.

Reasons for lack of trauma team

In the hospitals that did not have a trauma team 86% (6/7) identified staff availability as the major reason why a trauma team is not present. Other identified reasons included, too close to major trauma centre (2/7) and too few trauma patients (2/7). Just over half (57%) recognised that the formation of a trauma team at their facility may positively impact patient outcomes, and 57% also identified potential benefits for the centre at which they work if there were not the barriers as mentioned earlier with workforce issues.

Anaesthesia department involvement in trauma teams

Of the 21 responding hospitals with a trauma team system 62% (13/21) had involvement of a member of the anaesthesia department in the form of consultant, registrar or both responding to a trauma call. Large tertiary hospitals in the upper North Island did not include anaesthesia, but the smaller hospitals and South Island trauma hospitals incorporate an anaesthesia member into their teams. Furthermore, 50% (14/28) of respondents felt anaesthesia was best to manage airway in major trauma, and 79% (22/28) felt anaesthetists possess skills beneficial in the management of major trauma. Eighty-two percent (23/28) of respondents agreed that anaesthetists would probably or definitely add value to initial care of major trauma patients. Those that did not include anaesthesia in their trauma teams all indicated they would be involved if specific intervention was required.

Discussion

This study has shown that the use of trauma teams is common in New Zealand hospitals, with all regional and tertiary trauma centres having a trauma team response process, suggesting the majority of patients suffering major trauma are received by a trauma team. There was a wide variation in team composition, trauma call activation criteria and anaesthetic involvement.

An organised trauma team present at the time of arrival of a major trauma patient to the ED is known to have a positive impact on patient care.[[9]] The number of members within this trauma team varied significantly across the country, similarly to the international experience.[[10]] The median number of members being 10 is in line with a national study from the Netherlands.[[10]] Trends in the research however suggest the ideal number is less than this, citing a number of five to eight as the ideal number for adequate skill mix without compromising team leader oversight.[[13]] Across New Zealand, only 23% (5/21) of trauma teams fell within the recommended team size, with the majority of teams being larger. This has implication across New Zealand, as without a well-organised team there is the potential for team fragmentation, resulting in unnecessary procedures and the team leader losing oversight of the trauma resuscitation.[[13]]

The rate of trauma team utilisation is higher than many other countries where the rates vary from 21% to 98%.[[10,14–20]] This may reflect the well-developed trauma systems in place within New Zealand.[[21]] Future research may be able to provide comparisons with countries that have lower trauma team utilisation and major trauma outcomes to determine potential benefit to this high rate.

Smaller rural hospitals (≤52 beds) were unable to utilise a multidisciplinary approach to trauma care due to restrictions related to staff availability. These hospitals would generally be staffed by rural medicine specialists, and it is unlikely there would be any other medical specialties available to form a multidisciplinary trauma team. A formal trauma team response would also generally be unnecessary, as they are preferentially bypassed by major trauma patients if clinical condition allows. It is, however, reassuring of substantial clinician recognition of the benefits of such an approach to both the patient and institution.

Although there were large variations in team member numbers across New Zealand, there were a number of clear trends in roles allocated during trauma resuscitation. Geographical trends showed tertiary hospitals in the more northern regions utilising ICU more so than anaesthesia. The reasons for this are likely due to local availability of specialities to attend trauma calls. However, these roles were flexible. This may be good to overcome shortfalls however if team members are required to work outside their predetermined roles there is the potential for this to lead to non-optimal outcomes.[[22]] There is not clear evidence that the inclusion of intensive care or anaesthesia members in the team is beneficial over another however this may be an area of future study particularly regarding effectiveness of airway management and transit time to theatre or ICU. It may be also important to recognise the significant cross over between these specialties that still exists within New Zealand, which may limit the ability to conduct this investigation.

All hospitals that indicated a trauma team present had coverage 24 hours per day, seven days a week. However, the composition after hours changed in 76%, with the main change being a more junior team. Subsequently a more junior team with less experience dealing with major trauma may be unsure of their roles and responsibilities. This, however, is similar to the international experience with Australian studies demonstrating a rate of 74%.[[15]]

Hospitals with trauma teams utilised a criterion which incorporated aspects of physiological parameters and injury patterns for mandatory trauma call activation and discretionary calls based on injury mechanism. Table 3 outlines the specific criteria that was used by the responding hospitals. When comparing the criteria across New Zealand, there were many minor differences which has the potential to cause confusion. Specific examples include some criteria stating reduced GCS as a physiological parameter for a trauma call while others required specific GCS <14, <13, <12 or <9. Some even had specific time frames that this drop in GCS was required to be longer than five minutes. Similar trends were noted in the heart rate and respiratory rate requirements, with numbers for tachycardia and bradycardia to trigger a trauma call different across sites. There was, however, some standardisation across one of the trauma networks. There may be an argument that greater standardisation across trauma networks may improve familiarity with trauma call requirements. This may be particularly pertinent to those that rotate between hospitals, namely training registrars and there is evidence that standardisation within healthcare and specifically trauma systems can improve patient outcomes.[[23,24]] Although trauma team members may be required to be tailored to availability at certain hospitals, trauma call criteria is an area where there is potential for standardisation of practice.

Within the international literature, there is a trend towards utilisation of a two-tiered trauma call system. The reasons for this include avoiding a “cry wolf” situation where teams become fatigued from frequent calls and responses.[[25]] With a single-tiered system, there appears to be an increased risk of under triage, which Thoresen et al. determined translated to a significant increase in mortality within a Norwegian trauma system.[[26]] A 2–3x over-call rate is thought to be an acceptable level to prevent under call yet not cause significant team fatigue.[[27]] Trends across New Zealand demonstrate that 66% (14/21) trauma call response is a single-tiered response, meaning the same team attends for all trauma call. A two-tiered system could be explored and implemented within New Zealand with the potential benefits to decrease overcall rates, as well as reducing under triage, improving healthcare resource utilisation with potential for cost benefits.[[15,26]] Further research into the rates of over-call and under-call of trauma calls in the New Zealand context would be beneficial. During the composition of this study a national best practice critical bleeding bundle of care was being rolled out nationally, including a code crimson protocol.[[28]] The introduction of “code crimson”, which is a rapid transfer protocol for the critically bleeding patient has the potential to increase the number of tiered trauma call responses, depending on the current team that attends at the particular hospital.

Across the literature the involvement of anaesthesia appears to have regional variation, a variation which is seen across New Zealand.[[10,15]] Although the Australian and New Zealand College of Anaesthetists stops short of making recommendations about the attendance of anaesthetists in trauma teams, attendance as part of a trauma team is a requirement of training.[[29]] The Royal College of Anaesthetists, United Kingdom, however, mandates that an anaesthetist should be present as part of the team receiving major trauma patients.[[30]] This is something for consideration within the New Zealand context. As mentioned previously, it is not suggested that the inclusion of anaesthetists will directly improve patient outcomes but, importantly, that those who are involved in the management of trauma should have adequate exposure to volume of practice to maintain skills and knowledge. This could be by direct involvement in trauma team management of patients or other training methods.

This study is limited by survey respondent selection issues and respondent accuracy which was unable to be confirmed. However, the overall response rate was high and the majority of respondents were experts in trauma.

Conclusions

Trauma teams in New Zealand are common with the majority of major trauma patients treated by a trauma team. Hospitals that routinely receive major trauma patients have trauma teams and non-trauma hospitals do not. There is a wide variation in the number of members included in trauma teams as well as the trauma call criteria utilised. Anaesthesia departments are involved in over half of trauma teams, with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

View Appendices.

Summary

Abstract

Aim

Improved survival of trauma patients has been shown when a multidisciplinary trauma team is available. The aim of this study is to investigate the composition of trauma teams, trauma call criteria and the role of anaesthetists in trauma care across New Zealand.

Method

A survey was distributed using the modified Dillman’s technique. Data was collected and aggregated using an online platform. The survey consisted of two streams of questions depending on trauma team availability. Trauma nurse specialists were the first contact point and if not available, direct contact with the hospital was made for completion of the survey.

Results

Seventy-five percent of hospitals had a trauma team and trauma call system and correlated to size of the hospital. The number of trauma team members ranged from six to 17, with a median of 10. Trauma call activation criteria encompassed physiological criteria, injury pattern and injury mechanism criteria. Physiological criterial of GCS, heart rate, blood pressure and respiratory rate were universally used. Sixty-two percent of trauma teams had involvement of anaesthetists.

Conclusion

Trauma teams in New Zealand are common in regional and tertiary trauma hospitals. There is a wide variation in member numbers and criteria to trigger a trauma call. Anaesthetist involvement was in over half of trauma teams with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

Author Information

Dr Rohan Lynham BMBS, BHlthSc (Paramedic), EMCert: Anaesthesia Registrar, Auckland City Hospital, Auckland District Health Board, New Zealand. Dr Matthew McGuinness MBChB, MHSc: General Surgery Registrar, Invercargill Hospital, Southland District Health Board; Honorary Academic, The University of Auckland, New Zealand. Mr Christopher Harmston MBChB, FRCS(Eng), FRACS: Consultant General and Colorectal Surgeon, Northland District Health Board, Associate Professor, The University of Auckland, New Zealand.

Acknowledgements

We would like to thank the health professionals who completed the survey. Funding: Survey monkey™ platform was funded by Northern Regional Trauma Network.

Correspondence

Dr Rohan Lynham: c/- Anaesthesia department, Auckland City Hospital, 2 Park Road, Grafton, Auckland. Ph.: +649-367 0000

Correspondence Email

rlynham@outlook.com.au

Competing Interests

Nil.

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