Systems of Care in the Management of Vascular Injury

Trauma Systems Overview

Managing severe injuries requires the timely intervention of multidisciplinary teams, as well as the coordination of prehospital care and resuscitation begun at the point of injury. Fundamentally, trauma systems save lives by rapidly delivering critically injured patients in optimal condition to specialist surgical teams. The delivery of these patients to specialized trauma centers has repeatedly demonstrated significant reductions in mortality compared with non-specialist centers.

A regional trauma system is a public health model that seeks to optimize outcomes among injured patients for a defined population. A true trauma system treats trauma as a disease entity. The system covers the whole patient pathway, from prehospital care, transportation, and the acute management of injury through the reconstruction and rehabilitation phases. Included in this public health approach is a responsibility for injury prevention in order to actively reduce the burden of disease in the population. This approach also includes a strong commitment to system-wide data collection and analysis, which is utilized for performance improvement across the entire spectrum of patient care.

A trauma system goes beyond simply designating one hospital as a “Level I trauma center” conjoined with bypass protocols that send all injured patients to this institution. While this model may improve care for the severely injured, it has the potential to worsen outcomes for less seriously injured patients treated at the same center. Patients with mild to moderate injuries—who constitute 85% of all trauma patients—will suffer from de-prioritization within an overloaded hospital. Systems that comprehensively address the needs of patients within a given area (so-called “inclusive trauma systems”) incorporate all acute hospitals in a region and have been shown to produce better outcomes for a patient population. Hospitals in an inclusive system are designated according to their capabilities and institutional commitments. In the United States, levels of capability are designated with a system from level I to level IV. In the United Kingdom, centers are designated as major trauma centers (MTCs), which manage severely injured patients, and trauma units (TUs), which manage mild and moderately injured patients. Other countries and military entities have similar tiered levels of care.

Patients with vascular injuries are among the prime beneficiaries of the organized delivery of trauma care. The prompt resuscitation and early delivery of patients with active hemorrhage or ischemic limbs to a multidisciplinary vascular-trauma service can save lives and limbs. Additionally, there tends to be considerable overlap in the personnel, expertise, resources, and infrastructure required to deliver complex trauma care and complex vascular care. These synergies can improve outcomes for both trauma and non-trauma emergency vascular patients alike.

Key Components of a Trauma System

The purpose of a regional trauma system is to reduce death and disability following injury, while ensuring efficient use of resources and personnel. Not all hospitals can be staffed and equipped to manage all injuries. Major trauma patients must be identified early in their clinical course and directed to definitive care in a flexible and error-tolerant system that can deliver high quality clinical outputs. Key facets of a trauma system therefore include the following:

• 1.

  A prehospital care system that is closely integrated into the trauma system, with defined protocols to expedite patient triage

• 2.

  A regional trauma coordinating system integrating prehospital and hospital care to identify and deliver patients to a place of definitive care quickly and safely with proper notification to the hospital team

• 3.

  A network of hospitals with defined capability and capacity, and with predetermined transfer agreements for optimizing casualty flow

• 4.

  Specialized and designated regional trauma centers that have responsibility for the management of injured patients in the region

• 5.

  Acute rehabilitation services to improve outcomes and restore casualties back to productive roles in society

• 6.

  A continuous process of system evaluation, governance, and performance improvement across the trauma network

• 7.

  Ongoing training and education for all healthcare professionals involved in the care of injured patients

• 8.

  An active injury prevention program to reduce the burden of injury for the population that the trauma system serves

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  A responsibility toward research into trauma and its effects, to continuously improve care and outcomes following injury

• 10.

  A system-wide plan for response to disaster and mass casualty incidents

The primary function of the system is to identify each trauma patient as soon as possible in the clinical course, to render appropriate treatment, and to ensure swift transfer to the most appropriate facility. In the case of major trauma, this will involve directing the patient from the point of injury to the nearest trauma center that can care for the patient, while beginning resuscitation at the point of injury.

In the event that a patient arrives at a facility that is not equipped to provide definitive care within the trauma system because triage protocols are inadequate or misapplied, or because the patient arrives unannounced, the local facility must maintain sufficient trauma capabilities in early resuscitation to optimize patients for secondary transfer to a higher level of care. The regional trauma center must maintain the ownership of these patients and help coordinate their timely disposition and early resuscitation. In these scenarios, patients may be transferred in unstable conditions, and there must be expertise within the system to provide ongoing resuscitation during transport, as well as continued coordination with the receiving institution in order to expedite care. This is particularly important for patients with demonstrated vascular injuries. The rapid resuscitation and control of hemorrhage, particularly from an extremity, can stabilize patients for transport to definitive care that otherwise would not survive transport.

Once injured patients arrive at regional trauma centers, the infrastructure of the institution must ensure timely availability of the trauma team, ancillary staff, blood products, operating room capabilities, and required specialist and consulting services. The primary trauma team should maintain the ownership of these patients throughout their hospitalization and coordinate between consulting and ancillary services as needed.

The system also includes acute and chronic rehabilitation services both in the hospital and beyond. Patients managed at a trauma center should eventually be repatriated to the local community as soon as possible following definitive care. This maintains the capacity of the trauma center, while ensuring that patients can access appropriate community services and rehabilitation teams.

Additionally, the primary trauma team must continuously engage in quality improvement across the entire spectrum of care in order to continue to deliver the best care possible, from the point of injury to rehabilitation and return to preinjury status. Quality improvement (QI) can be conceptualized as follows:

A method of evaluating and improving processes of patient care which emphasizes a multidisciplinary approach to problem solving, and which focuses not on individuals but on systems of patient care that may be the cause of variations. QI consists of periodic scheduled evaluation of organizational activities, policies, procedures and performance to identify best practices and target areas in need of improvement and includes implementation of corrective actions or policy changes where needed.

This involves feedback as appropriate to the prehospital team, transferring facilities, and consulting services, as well as internal review of quality and performance of the trauma team and the trauma center. This also includes periodic review and accreditation by independent reviewers to ensure compliance with best practices and benchmarks developed by the broader community of trauma specialists, both regionally and nationally.

Travuma QI is not only the province of mature trauma systems in well-resourced settings, the principles of QI are equally applied to trauma care across the entire range of trauma systems, including those with minimal resources and austere environments. Importantly, a regional system delivers trauma care that achieves these benchmarks with local solutions that reflect its own particular geography, resources, and capabilities.

Within the trauma system, the provision of quality care is linked to both designation status and financial reimbursement. It is possible for trauma centers to lose their status and for previously undesignated institutions to gain status as trauma centers depending on their ability to demonstrate quality care and a commitment to performance improvement. An independent team that periodically reviews the quality, quantity, and capacity of the institution determines designation status. These periodic reviews also allow for the identification of areas for improvement and function as part of the broader quality improvement and standardization of therapy across institutions.

There is a growing body of evidence that the institution of dedicated trauma centers can improve outcomes for trauma patients across a variety of metrics. In addition to demonstrably more lives saved, trauma centers by virtue of increased knowledge, experience, resources, and personnel are able to provide higher quality and more efficient care, even to those patients without fatal injuries. The upfront cost is significant and varies by region, but the provision of expert and efficient care represents overall a cost savings to the community served. Around the world, the implementation of trauma systems has resulted in consistent mortality reductions, and ongoing quality improvement within these systems should yield increasing cost effectiveness as these systems mature. Patients with vascular injury are the most likely to benefit from robust and well-integrated trauma systems, as this patient population is at high risk for rapid decline due to hemorrhage and the necessity of urgent surgical intervention.

Trauma Center Function

When a hospital is designated as a regional trauma center, it accepts responsibility for the delivery of injury care to all people living and working within its catchment area. The trauma center has a duty to ensure that injured patients will receive high-quality trauma care at the most appropriate hospital and in a timely manner. Furthermore, it is responsible for the continuum of care, from the first prehospital response through completion of rehabilitation, including the quality of care received at other trauma-receiving hospitals within its region. The center also has a public health duty to reduce the injury burden through injury prevention activities for its population.

Trauma centers have all surgical specialties required for the care of multisystem trauma patients, as well as on-site and in-house trauma team coverage 24 hours a day. There is capacity and expert support from diagnostic and interventional radiology, transfusion services, critical care, rehabilitation, and other allied services. However, the mere presence of these services will not be sufficient for the designation of a regional trauma center, because improvements in outcomes and the process of care are only seen when the overall responsibility of the care of trauma patients is managed by a specialist trauma service.

The function of the trauma service is to provide expert care for trauma patients, integrating the care of multiple teams and advocating for patients, both within the hospital system and during ongoing community care. The service is responsible for trauma education to all staff involved in trauma care, ensuring appropriate certification and ensuring that best practice guidelines are understood and implemented. Typically, the service will receive all new trauma patients and direct their early resuscitation and assessment. Additionally, the trauma team will determine their observation or admission status and will perform a tertiary survey and radiology review on all evaluated patients to ensure no injuries are missed.

Patients with a single system injury (e.g., isolated brain injury or isolated tibia fracture) may be signed over to the appropriate specialist team, but patients with combined injuries (e.g., brain injury and a tibia fracture) remain under the care of the trauma service with appropriate specialty input. The final responsibility to ensure delivery of quality trauma care remains with the trauma service for all admitted trauma patients.

The trauma service is a multidisciplinary team made up of surgeons, specialist nurses, occupational therapists, physical therapists, respiratory therapists, pharmacists, data collection staff, and administrative staff. Trauma-trained general surgeons with experience or additional certification in critical care lead most trauma teams. Trauma program managers, trauma nurse coordinators, and nurse case managers are also essential to the daily activities of the service, whereas the data collection staff monitors the health of the system and compliance with quality improvement initiatives.

Turning a multispecialty hospital into a specialist trauma center is not a trivial task, and it involves a significant investment in staff and resources, as well as changes in the delivery of health care and clinical governance. Managing the interface between other hospitals in the region and prehospital care providers requires commitment, communication, education, and intense coordination. Despite this, the cost to implement trauma centers and regional systems is relatively cheap and the potential savings from minimized disability and loss of life represent a large net gain for the community and region served.

Trauma Systems in Combat Casualty Care

At the time of this publication, US, UK, and other NATO military medical forces deployed in support of operations in Iraq and Afghanistan have provided continuous combat casualty care for nearly two decades. This medical response initially lacked a cohesive and structured approach. Communication lines between individual medics/corpsmen, forward operating bases (FOB), combat hospitals, and evacuation facilities did not exist: the prehospital environment was essentially isolated from the hospitals and tertiary/quaternary care facilities. Hoping to recreate the positive impact of civilian trauma systems on patient outcomes, a group of military physicians advocated for a theater trauma system based on the civilian model.

In late 2004 to early 2005, US Central Command (CENTCOM) implemented an inclusive system of trauma care for its entire area of operations designated as the Joint Theater Trauma System (JTTS). Simultaneously, the UK Defense Medical Services began an independent, yet strikingly similar, endeavor to build an ad hoc trauma system for its forces engaged in Iraq and Afghanistan. The stated vision of the JTTS was to ensure that every soldier, marine, sailor, and airman injured on the battlefield had the optimal chance for survival and had maximal potential for functional recovery—“the right patient to the right care in the right place at the right time.” Although the epidemiology of military trauma differs from civilian centers, the American College of Surgeons Committee on Trauma (ACS COT) text entitled Resources for the Optimal Care of the Injured Patient served as a useful model for the structure, function, and role of the JTTS. This document, commonly referred to as “the Orange Book,” identifies criteria for civilian trauma care resources and practices in an effort to optimize standards of care, policies, procedures, and protocols for care of the traumatically injured patient. The content of the manual provides guidance for medical care personnel from the prehospital arena through hospital and subspecialist care. The ACS COT Verification Review Committee (VRC), initially developed in the early 1970s, functions as the oversight process and verifying entity for the American trauma care system.

Following the example of the ACS COT, the JTTS identified and integrated processes and procedures to enable recording of trauma patient–related data at all levels of care to promote continual process improvement. Establishment of the Department of Defense (DoD) Trauma Registry (DoDTR) provided a comprehensive resource for the collection of all DoD trauma injury data. These essential data were used to predict needed resources, evaluate outcomes, educate staff, and identify training needs in order to improve continuity of care across the combat care continuum. It was essential in facilitating real-time, evidence-based changes in these conflicts. Oversight and direction for the theater trauma system above level I is directed by the CENTCOM surgeon. The US-based parent organization, now known as the Joint Trauma System (JTS), was founded primarily to manage the DoDTR. JTS embraced the system concept for providing continuity of care from the point of injury to medical treatment facilities to rehabilitation centers in the continental United States. A philosophy of continuous improvement drove and matured the system. The JTS now exceeds the capabilities of the US trauma care system on which it was modeled.

Prior to 2016, the JTS was a directorate within Joint Base Sam Houston; in the fall of 2016, the recommendation was made by the Under Secretary of Defense to establish the JTS as an independent authority and lead agency for trauma in the DoD. With the realignment of US military medicine and the incorporation of the Defense Health Agency (DHA) in 2017, the JTS was finally named as the governing body of trauma care in military medicine. The National Defense Authorization Act of 2017 (NDAA17) established the Combatant Command Trauma System (CTS) as the successor of the JTTS. NDAA17 also granted JTS the power to serve as the reference body for all military trauma in an effort to establish standards of care for trauma services provided at military medical treatment facilities (MTFs). Additionally, JTS was directed to coordinate the translation of research from the DoD centers of excellence into standards of clinical trauma care and to coordinate the incorporation of lessons learned from the trauma education and training partnerships into clinical practice. Experiences from prior US wars and conflicts were largely lost as providers retired and time passed. Establishment of the JTS ensured that corporate memory is preserved, and that benefits of the current system will be available to future surgeons/conflicts.

Organization of the Joint Theater Trauma System

There are five levels, or “roles,” (known as echelons in most NATO nations) of care in the US military trauma-care system. Each role has progressively greater resources and capabilities ( Tables 3.1 and 3.2 ). Role I care provides aid at or near the point of injury. Role II care consists of surgical resuscitation provided by forward surgical teams that directly supports combatant units in the field. Role III care provides a much larger and resource-capable facility and serves as the highest level of care within the theater of operation. Generally speaking, military role III centers offer advanced medical, surgical, subspecialist, and trauma care: they are similar to civilian level I trauma centers or MTCs. Transfer of casualties between roles I and III is generally via rotary or fixed-wing tactical airframes.

Role IV care is the first level at which more definitive surgical management is provided outside the combat zone. For US forces in the Afghanistan (and Iraq) theater, this is Landstuhl Regional Medical Center (LRMC) in Germany. Role V care is the final stage of evacuation to one of the major military centers in the continental United States (CONUS). At a role V facility, there is not only definitive care, there are also more comprehensive rehabilitation services. Transfer of casualties between role III and role IV/V facilities is by specialist strategic aeromedical evacuation or by Air Force Critical Care Air Transport Team (CCATT). The UK military system has similarly structured in-theater care from echelon 1 through to echelon 3—generally analogous to US level I to III, with the Royal Centre for Defence Medicine at Queen Elizabeth Hospital Birmingham (University Hospitals Birmingham NHS Foundation Trust), United Kingdom acting as their highest tier.

The elements that comprised JTS were bound by an overarching leadership that was tasked to continually assess system structure, function, and outcomes, while creating policy and guidelines based on the analysis of their assessments. An understanding of the epidemiology behind specific injury mechanisms and casualty injury burden is essential to placing these functions in proper context. Each of the following functions is central to adjudicating trauma system efficacy:

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  Assessment: includes the ability to thoroughly describe the epidemiology of injury within the theater jurisdiction and to scrutinize the efficacy of care via access to databases depicting performance metrics across the continuum of care.

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  Key policy/guideline development: includes comprehensive authority to maintain trauma system infrastructure as well as planning, oversight, and command authority to create and enforce policy and guidelines on behalf of the welfare of the injured.

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  Assurance: includes education and coalition building with leaders and participants across the system to foster cohesion and collaboration. Also includes the use of analytical tools to monitor performance, promote injury prevention, and to evaluate and verify that system components meet agreed-upon criteria.

Successful implementation of these functions with regard to military trauma care capabilities in Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation Inherent Resolve (OIR) led to the lowest case-fatality rates recorded for combat casualty populations.

A major challenge arising from the conflicts has been determining how to turn the past successes of the JTTS approach, developed in Afghanistan and Iraq, into strategies that will assure care to military populations deployed on future operations. JTTS was built around a very static and stable network of medical facilities backed up by robust and largely guaranteed aeromedical evacuation routes. The system dealt with large volumes of injured combatants over several years, often being treated by seasoned clinicians who served on multiple tours. Such enduring conditions were fertile for systemization and quality improvement. Future operations, predicted to involve near-peer threats, are likely to be lighter and shorter, take place in areas where we will not have established infrastructure, and involve less assured logistic and evacuation options. The “opportunity cycle” within which it is possible to characterize problems, launch improvement initiatives, observe for effect, and revise accordingly may be much less favorable than during the JTTS era. Developing swifter, more agile systemization methodologies and improvement mechanisms that not only take account of new operational realities but thrive within them is an emerging problem that must be tackled successfully by DHA and JTS in order to continue delivering the best results.

Challenges of Vascular Injury Care

If it is clear that the outcomes for injury can be improved by a systemized approach, what are the barriers and challenges faced by surgeons wishing to address the specific problem of vascular injury within a trauma system?