a plea for croatian trauma system
TRANSCRIPT
Injury, Int. J. Care Injured 44 S3 (2013) S3–S6
Introduction
In Croatia, 4.3 million citizens are unevenly distributed
over 21 counties, with an average population density of 75.8
persons per km2. The rate of natural increase is negative and the
population trend demonstrates aging.
Measured by GDP per capita, Croatia is considerably behind
the EU average. The unemployment rate is high, and economic
indicators are currently negative. Consumer prices show a
significant increase in health care and energy prices. More than a
third of Croatian citizens are at risk of poverty and social exclusion.
35% of Croatian territory refers to the sea with 1244 islands,
among them only 48 are permanently populated. During summer
season, seaside is overcrowded with more than 11 million tourist
which puts addiotional pressure to the organization of health
care.
During the past ten years, the third leading cause of death
in Croatia was due to external causes of injury and poisoning
(ICD-10 code: V00-V99, W00-W99, X00-X99, Y00-Y99).1 In 2010
standardized death rate (SDR) was 52/100,00 0 (EU average:
36/100,000).2 Top causes were falls (36%), suicide (26%) and traffic
accidents (17%). Children and young people (0-39 years) mostly
die due to road traffic accidents, middle-aged (40-64 years) due
to suicide, and elderly (+65 years) due to falls.1 In 2010, SDR due
to road traffic accidents in Croatia was 9.59 (EU average: 5.97).2
Basic health insurance is compulsory and carried out by state
governed Croatian Institute for Health Insurance. Supplementary
and private health insurance is voluntary. There are three levels
of care. Primary health care is provided by general practitioners
(i.e. family doctors), gynecologists, pediatricians (for infants and
preschool children only), dentists, occupational medicine and
pharmacists, mostly on the basis of concessions or in private
practice. Health facilities at the secondary level are owned by
counties. These include rehabilitation centers, clinics and small
hospitals. Tertiary level comprises 11 university clinics, all but
one owned by the state. More than one half of the university
clinics are located in the capital city. Capital city has less than
20% of the total population in Croatia.
Pre-hospital setting
In Croatia, the term “emergency medical service” (EMS) is
constrained exclusively to the provision of medical aid in pre-
hospital setting, although emergency departments in hospitals
also function. In this narrow term, EMS is considered as a part
of primary health care owned by counties, even tough it is
controlled and paid by the state insurance fund.
There are four lines of treatment:
- Fully equipped ambulance car with EMS physician, registered
nurse and driver (Team 1)
- Fully equipped ambulance car with two EMS nurses (Team 2)
- General practitioners on call, mainly in rural areas. Official
estimates suggest that 4/5 of population is covered by EMS,
and the remaining 1/5 by general practitioners.1
- Immobile, but non acute patients are accompanied by EMS
driver in an ambulance with basic equipment. This kind of
health service is in the process of separation from EMS.
Croatian counties differ significantly in total area and
population density. For example, Zagreb has population 1,232
K E Y W O R D S
Croatia
trauma
trauma care
trauma system
A B S T R A C T
This paper provides an insight into Croatian health system with special focus on trauma care. The
current situation is explained from a domestic point of view, but an independent review by foreign
observers is also included.
Fragmented approach to the treatment of injured patients in Croatia should be replaced by networking
of health care componenets into a unique chain of help. The concept and five methodological steps in the
development of a succesfull trauma system are presented. A good start is definitely a reorganization of
existing knowledge on the basis of internationally licesed courses and the adoption of trauma registry
as a standard for future discussion. Individual components of the trauma system can not be separately
“optimized” so clinical and financial decisions should be planned exclusively on the integral level.
© 2013 Elsevier Ltd. All rights reserved.
A plea for Croatian trauma system
Tonisav Antoljaka,*, Ivan Dobrica, Bore Bakotab, Tomislav Zigmana, Daniel Rajacica, Tin Ehrenfreunda
aDepartment for Traumatology and Bone & Joint Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, CroatiabDepartment for Surgery, General Hospital Karlovac, Karlovac, Croatia
* Corresponding author at: Department for Traumatology and Bone & Joint
Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, Croatia
E-mail address: [email protected] (T. Antoljak).
0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
Contents lists available at SciVerse ScienceDirect
Injury
j our na l homepage: www.e lsev ie r.com/ loca te / in ju r y
S4 T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6
people/km2 and Licko-senjska County only 10 people/km2.
During 2010, one EMS team covered nearly 10,000 people and
each of them had 2,687 interventions in average. The average
medical transportation time was 49 minutes and 45 seconds.
Under special conditions, army facilities can be activated for
emergency medical air transportation and in 2011 there were
1,387 flights totally. Boat transfer is also available on inhabited
islands, but the means of transportation are rather inappropriate.1
Couple of years ago, specialization in EMS for physicians
was introduced in Croatia, but without a clear vision whether
it should be pre-hospital or hospital based profession. Senior
physicians, former GP’s, were promoted to the status of a
specialist, but without any formal examination, and the younger
ones started their residency mainly in hospitals.
Hospital setting
A total of 29 acute hospitals are participating in trauma
network. Each of them carries the responsibility for a certain part
of the country on equal basis though they vary considerably in
human capacity and equipment. In other words, the accreditation
process in Croatia has not started yet, although the government
agency was established few years ago. Due to the lack of
corresponding specialists, hospital emergency departments
still functions in fragmented sections. All together, this causes a
clear inequality of initial trauma care, depending on geographic
location of injury.
Review from abroad
Thanks to MATRA funds, two projects were accomplished
during 2008 and 2009 in cooperation between Croatian ministry
of health on one side, and Dutch ministry of foreign affairs, Dutch
ministry of health and Dutch Association of trauma centers on
the other. These projects were: “Developing Croatian Trauma
System through open communication” and “Empowering the
professional through networks”. A high delegation of Dutch
experts visited Croatia several times with objectives to gain
insight into present trauma care in Croatia and to assist in the
policy development of future Croatian trauma system.
In a written report to Croatian government it was clearly
stated that present level of trauma care in Croatia is not up to the
standards of EU. It was strongly advised to the Croatian Ministry
of Health to improve this situation and create equal access to
trauma care throughout Croatia.
Besides this core finding, few other problems were
highlighted:
- Heterogeneity in human resources, training and equipment
- Absence of group goals, methods and priorities
- Discoordination among health care segments, especially
between pre-hospital and hospital setting
- Unawareness of unique chain of help in trauma care
- Lack of objective data (trauma registry)
- Lack of leadership in decision-making
From Croatian point of view, the following remarks from
Dutch colleagues are worth mentioning:
- Personal attitudes prevail instead of written protocols,
guidelines and standard procedures
- Discussions are dominated by individual opinions whose
acceptance depends on the position of the debater in the
hierarchy
- Changes are hard to achieve because health care professionals
do not tend to accept ideas from other professionals,
institutions or trauma care segments. They call upon the
government to take some action and use formal power to
overcome these shortcomings as if they are still functioning
in the centralized system they once had.
- The government is taking initiatives, but until now not in a
coordinated and concerted manner. It takes time for plans
to be implemented and after that additional time is needed
to check the programs in health care practice. Unfortunately,
plans in Croatia are already changed or stopped before
they become really effective because of changing political
priorities or shortage in funding. Both the government and
health care professionals are consequently frustrated.
Steps to be taken
Trauma system is an organized, coordinated effort in a defined
geographic area that delivers the full range of care to all injured
patients, and which is integrated with the local public health
system.3 According to the definition, key components of the
system are: pre-hospital care, acute hospital care, rehabilitation
and public health measures. Under circumstances of sharp
division am ong these links, the main challenge is to connect
all of them into a firm chain of help to injured people using
communication and coordination activities as well as ongoing
evaluation processes.
Four premises are essential:
1. Saving life is of highest importance, not reducing disability
2. Injury is not a simple sum of individual diagnosis, but a
complex condition/illness causing a reaction of the whole
organism
3. Due to the complexity of injury, trauma patients require
multidisciplinary treatment
4. Definitive treatment of injured people should be carried out
not in the nearest, but in the nearest competent hospital.
Following international experience,3–7 a trauma system should
be developed using five steps:
1. Reorganization of existing knowledge of health care
professionals
2. Development of standardized trauma units
3. Organization of trauma centers through intrahospital
integration of health care capacities
4. Organization of trauma system through coordination of
health system with other public services
5. Promulgation of trauma system as a factor adding to social
stability. This is of particular importance in Europe, because
injuries affect mostly less privileged people.8,9
Injuries are life threatening conditions which occur suddenly
and unexpectedly. For this reason, their treatment should have
the highest priority, above all other emergencies in medicine.
Even more, treatment of injuries requires teamwork which
implies demonstration of high quality of common knowledge
under stress.
Problem of postgraduate education has already been recog-
nized in developing countries.10–14 In at least one of them,
Trinidad, a regular institution of internationally licensed courses
has been documented to lower the mortality rate of trauma
victims.15–17
Without any doubt, health care staff in Croatia has a
respectable amount of knowledge. However, this knowledge is
accumulated in postgraduate period on an individual basis and
according to personal preferences, and it is largely financed on
own expense. Therefore, it is of uneven quality and very often
fragmented.
In Croatia, a key component of improvements in trauma care
should be optimising training using internationally licensed
courses. This provides the following priorities:
T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6 S5
1. Determining the minimum of common knowledge in trauma
care
2. Establishing clear priorities in treatment of injured persons
3. Installation of evidence based medicine (EBM) as the only
correct way in treatment of acutely injured people
4. Teamwork training
5. Licensing and relicensing of health care staff based on
professional standards rather than on academic knowledge.
Regarding this issue, the situation in Croatia is currently
not encouraging. Surgical Society, the principal professional
association, is not interested to introduce ATLS because of
high initial costs. Croatian Resuscitation Council has recently
started with ETC, but the courses are rare and expensive for an
individual. Starting from 2004, over 2000 doctors and nurses
completed ITLS training and the course has been well received.
On the other hand, ITLS is designed for pre-hospital setting, not
for hospitals, so it can not be the only part of the didactic core of
the future Croatian trauma system. Finally, Croatian Institute of
Emergency Medicine started in 2011 with some kind of education
sponsored by World bank. Since this effort is designed according
to personal preferences of the leaders, it does not address the
need for standardized education based on EBM.
Next to reorganization of knowledge based on internationally
licensed courses, a good start for the Croatian trauma system
would be data collecting in a single trauma registry. When
presenting the analysis, in should be born in mind that adverse
outcomes are not always a reflection of poor medical care. The
imprefection of the system causes the majority of mistakes,
rather than the individual.18
The second step in the development of the trauma system
is the organization of the trauma unit (TU). This is not an
observation room, not an operation theatre for elective surgery
and there are no regular patients. Spatially it can be an integral
part of the emergency department (ED) or separately organized
entity.7 Whichever option is chosen, trauma unit must be the
only admitting area in the hospital for the treatment of acutely
injured people. Due to the ongoing emergency procedures, key
criteria for construction and equipment should be efficiency,
affordability, simplicity and visibility.
Procurement and arrangement of equipment is the easy
part, but the real challenge is building trauma teams7. Trauma
team is a multidisciplinary, trained and organized group of
health care professionals who take the full responsibility for
emergency trauma patients.19 This goes well beyond the usual
procedures such as diagnosis and initial stabilization of vital
parameters.20 Important features of teamwork are: dedication
and commitment, complementary skills, mutual trust and
timely fulfillment of agreed tasks. Completing ATLS or ETC is a
prerequisite for teamwork in the trauma unit.
Some of the responsibilities of a team leader are: data collection
from pre-hospital service, setting priorities in the diagnosis
and treatment, the interpretation of patient data, coordination
of intra- and inter-hospital transfer, communication with
consultants and primary triage during disaster management.20
Although an anesthesiologist, general surgeon or EM specialist
can be nominated as a team leader, for Croatian circumstances
we strongly advocate trauma surgeons. During war in Croatia
1991-1995 they have proven their value and we do not support
recent merging of trauma surgery with orthopedics as suggested
from EU.
Having a well-equipped, well-operating trauma unit does not
make a shift from regular hospital to a trauma center.7 Actually,
trauma centers are verified acute hospitals where emergency
trauma patients have the priority over all other patients. Intra-
hospital integration of all necessary medical specialties needs to
be implemented in practice as they provide complete, coordinated
and efficient care to all injured people 24h/7 days. Besides,
trauma center should have developed systems for education,
injury surveillance, data collection and quality improvement.21,22
Good communication and cooperative relationships should be
maintained with other hospitals in region as well as transport-
and by pass-agreements.21,22 Coordination with other public
services is also required. These standards are hardly to achieve
without a lots of commitment from hospital administration.7
Most important point is that there is no need to build new,
special hospitals for trauma centers. All that is needed is to
reorganize the existing capacities upon new principles. Almost 14
years ago EU has announced a network of trauma centers along
major transport corridors to maximize the safety of passengers.
Each of these trauma centers should cover a population up to one
million people.23
A trauma center does not make a trauma system7. Main
feature of a good trauma system is to link prehospital, hospital,
rehabilitation and public-health efforts in a solid, uninterrupted
chain of trauma care.
In Croatia, pre-hospital EMS transports patients to the
nearest hospital. As well known, this can significantly decrease
the transport time in large, densely populated cities but might
have negative implications for in-hospital mortality, as centers
without adequate resources might be receiving patients for
which they are unprepared.24 On the other hand. the general
principle of a good trauma system in pre-hospital setting is to
identify and manage any life-threatening injuries, and then to
transport the patient to an appropriate facility as soon as possible
to receive definitive treatment.25–28 Any delay in the transport
time or delay in the ongoing treatment of life-threatening
injuries may jeopardize the common goal: saving as many lives
as possible. Therefore, we do not advocate “Stay & Play” or
“Scoop & Run” phylosophy in pre-hospital trauma care, but “Run
& Play”. We believe that ITLS in Croatia provides sufficient basis
for the achievment of this standard, so we strongly recommend
this course as a mandatory part of education of pre-hospital
personnel in Croatia, both doctors and nurses.
Although without EBM support on this issue, there seems
to be a trend in EU towards integration of pre-hospital teams
in hospital ED’s in order to increase the quality of trama care in
the field and to reduce costs.29,30 If this is true, then the nurses
should take over considerable responsibility in pre-hospital
setting. This process has already been started in Croatia through
activities of Croatian Institute of Emergency medicine (Team 2).
As monitoring parameters are not well defined, the future of this
project will depend again on the political will of the goverment.
For now, the introduction of paramedics in trauma care in Croatia
is not an option.
Particularly in the case of road traffic accidents, there is
no doubt that lay bystanders can play a crucial role.23 Besides
some actions like rapid extrication from a burning vehicle or
establishing a contact with emergency services, lay bystanders
need to be able to secure a free airway in unconsious victim
and to treat immediately major bleeding. This is particularly
important to reduce preventable deaths. The presence of gloves
in the car to protect the bystander during these actions is
desirable. Even more, there is no evidence to suggest that first
aid kits being made available in cars would help. In this sense,
we suggest a shift from the current targets of teaching of first aid
for drivers towards more modern knowledge. Basic ITLS would
be a good choice.
The need for transportation of injured persons to the nearest
competent hospital has been emphasized several times. In
other words, some hospitals in Croatia will be passed by in
the future trauma network due to lack of human resources or
S6 T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6
equippment. They will lose some of their importance, and
probably part of their income, while some other hospitals will
be increasingly burdened so they will ask for more money. We
agree that accreditation is an extremely delicate process with
a lot of political implications, but it has to be done. Because of
the potential impact on the survival and invalidity of trauma
patients, action between professional organizations and the
government must be coordinated and presented to the public on
the basis of clear and agreed information.
Finally, each trauma system has to be tailored to fit local
circumstances, but the program is effective only when it involves
the whole chain of help in trauma care, not just individual
links. Therefore, option advocated by Croatian Institute of
Emergency medicine is not satisfactory, because it relies just on
improvement of pre-hospital services. Mere question remains
what will be the trigger point that will bring together the
government, professional health care associations and citizens in
order to build a new organizational structure on the principles of
cooperation and goodwill as well as with respect to knowledge
and experience from abroad.
Conflict of interest
All authors declare they have no conflicts of interest.
References
1. National Health Development Stategy 2011-2020, Sept. 2012.
2. European health for all database, WHO Regional Office for Europe,
Copenhagen, Denmark, July 2012.
3. American Trauma Society: Trauma System-Agenda for the Future. 2002.
4. United Nations, General Assembly, 1 August 2003: Global Road Safety Crisis.
Report of the Secretary-General.
5. Advanced trauma life support for doctors. Instructor course manual, 6th ed.,
American College of Surgeons, Chicago; 1997.
6. SMARTRISK, Health Canada, Emergency Health Services Branch Ministry of
Health: The Economic Burden of Unintentional Injury in Canada; 1998.
7. Michaelson M. Building a Trauma System-The Rambam Medical Center
Experience. Trauma Care 12(2), Fall 2002.
8. La Flamme L. Social Inequality in Injury Risks. Knowledge Accumulated and
Plans for the Future. Sweden, Karolinska Institutet, 1998.
9. La Flamme L. Explaining socio-economic differences in injury risk. Injury
Control and Safety Promotion 2001;8(3):149-153.
10. Civil IDS. Trauma care - a team sport in the 21st century. Injury, Int. J. Care
Injured 2007;38:5—6.
11. Mock CN, Quansah R, Addae-Mensah L, DonkorP. The development of
continuing education for trauma care in an African nation. Injury, Int. J. Care
Injured 2005;36:725—732.
12. Dai K, Xu Z, Zhu L. Trauma care systems in China. Injury, Int. J. Care Injured
2003;34:664–8.
13. Civil IDS. Good trauma care doesn’t happen by accident. Injury, Int. J. Care
Injured 2005;36:689—690.
14. WHO: Prehospital Trauma Care Systems, Geneva 2005.
15. Ali J, Adams R, Butler AK, et al. Trauma outcome improves following the
advanced trauma life support program in a developing country. J Trauma
1993;34:890—8.
16. Ali J, Adams R, Stedman M, et al. Advanced trauma life support program
increases emergency room application of trauma resuscitative procedures.
J Trauma 1994;36:391—4.
17. Ali J, Adam RU, Gana TJ, Williams JI. Trauma patient outcome after the
Prehospital Trauma Life Support program. J Trauma 1997;42(6):1018-21.
18. Performance Improvement Subcommitteeof the American College of
Surgeons Committee on Trauma. Trauma performance improvement.
Reference Manual. Jan 2002.
19. State of California, Emergency Medical Services Authority. Chapter 7. Trauma
Care Systems, California, 2003.
20. Driscoll PA, Vincent CA. Organizing an efficient trauma team. Injury
1992;23:107–110.
21. West JG, Williams MJ, Trunkey DD, Wolferth CC Jr. Trauma systems: current
status — future challenges. JAMA 1988;259(24):3597-600.
22. Kortebeek JB. A review of trauma systems using the Calgary model. Can J Surg
2000;43:23-8.
23. European Transport Safety Council. Reducing the Severity of Road Injuries
Through Post Impact Care, Brussels 1999.
24. Roudsari BS, Nathens AB, Arreola-Risa C, Cameron P, Civil I, Grigoriou G et
al. Emergency Medical Service (EMS) systems in developed and developing
countries. Injury, Int. J. Care Injured 2007;38:1001—13.
25. Coats TJ, Goode A. Towards improving prehospital trauma care. Lancet
2001;357:2070
26. Kristiansen T, Søreide K, Ringdal KG, Rehn M, Krüger AJ, Reote A et al. Trauma
systems and early management of severe injuries in Scandinavia: review of
the current state. Injury 2010;41:444–52.
27. Mackersie RC. History of trauma field triage development and the American
College of Surgeons criteria. Prehosp Emerg Care 2006;10:287–94.
28. Sharma BR. Development of pre-hospital trauma-care system—an overview.
Injury 2005;36:579–87.
29. Council of the European Society for Emergency Medicine. Manifesto for
Emergency Medicine in Europe. European Journal of Emergency Medicine
1998;1:7-8.
30. Council of the European Society for Emergency Medicine: Manifesto for
Emergency Medicine in Europe, revision. European Journal of Emergency
Medicine 1998;5(4):1-2.