The shadows looming over a new era for trauma

By David Lynch - 04th Oct 2022 | 329 views

major trauma

With two major trauma centres due to commence operation by the end of the year, it remains to be seen how recruitment and capacity issues may hamper implementation of the new national system. David Lynch reports.

The coming months are set to mark the beginning of a new era for the Irish trauma system. 

“It’s a long journey and it will take many steps,” Mr Keith Synnott, HSE National Clinical Lead for Trauma Services, said last month. 

“We’ve got all the maps, we’ve got all the plans, but hopefully within the next month or two we’re going to take this first step on this long journey, which will take us towards full implementation of a trauma system for Ireland.” 

Mr Keith Synnott 

The Consultant Orthopaedic and Spine Surgeon was speaking at the recent launch of the Major Trauma Audit National report 2019 and 2020. Mr Synnott said that “we’re hoping to have major trauma services commence in each of the major trauma centres [Dublin and Cork] by the end of this year”. 

It is now four years since the Trauma System for Ireland plan was published. It outlined a “whole-system approach addressing all elements of the trauma care pathway, including prevention, pre-hospital care, acute hospital care, rehabilitation, and supported discharge”. The report recommended the establishment of an “inclusive trauma system”, where a network of facilities and services co-ordinate in the care of injured patients along standardised pathways. 

Implementation 

Concerns have previously been raised over the pace of implementation of the plan. While the Irish Association for Emergency Medicine (IAEM) is supportive, last year its President Dr Fergal Hickey highlighted to the Medical Independent (MI) the amount of time it was taking to implement. 

Speaking at the recent trauma audit launch, Mr Synnott said that much planning has been done, but that Covid-19 and the cyberattack had “interfered” with this work. 

“But despite that, we have made some progress and I think we are about to get our foot on the ladder towards implementing a trauma system as was envisioned in the report [Trauma System for Ireland].” 

According to Mr Synnott, a new trauma triage tool is to be rolled out in the system in the coming months. He added that there was a focus on “planned trauma care”. 

“This is building on the idea that a lot of patients who sustain injury don’t need acute admission, don’t need to wait on a trolley… their treatment can be delivered on a planned, often as a day case basis… we have defined a model of care for delivering planned trauma care and we are in the process of trying 

The coming months are set to mark the beginning of a new era for the Irish trauma system. 

“It’s a long journey and it will take many steps,” Mr Keith Synnott, HSE National Clinical Lead for Trauma Services, said last month. 

“We’ve got all the maps, we’ve got all the plans, but hopefully within the next month or two we’re going to take this first step on this long journey, which will take us towards full implementation of a trauma system for Ireland.” 

The Consultant Orthopaedic and Spine Surgeon was speaking at the recent launch of the Major Trauma Audit National report 2019 and 2020 (see panel). Mr Synnott said that “we’re hoping to have major trauma services commence in each of the major trauma centres [Dublin and Cork] by the end of this year”. 

It is now four years since the Trauma System for Ireland plan was published. It outlined a “whole-system approach addressing all elements of the trauma care pathway, including prevention, pre-hospital care, acute hospital care, rehabilitation, and supported discharge”. The report recommended the establishment of an “inclusive trauma system”, where a network of facilities and services co-ordinate in the care of injured patients along standardised pathways. 

Implementation 

Concerns have previously been raised over the pace of implementation of the plan. While the Irish Association for Emergency Medicine (IAEM) is supportive, last year its President Dr Fergal Hickey highlighted to the Medical Independent (MI) the amount of time it was taking to implement. 

Speaking at the recent trauma audit launch, Mr Synnott said that much planning has been done, but that Covid-19 and the cyberattack had “interfered” with this work. 

“But despite that, we have made some progress and I think we are about to get our foot on the ladder towards implementing a trauma system as was envisioned in the report [Trauma System for Ireland].” 

According to Mr Synnott, a new trauma triage tool is to be rolled out in the system in the coming months. He added that there was a focus on “planned trauma care”. 

“This is building on the idea that a lot of patients who sustain injury don’t need acute admission, don’t need to wait on a trolley… their treatment can be delivered on a planned, often as a day case basis… we have defined a model of care for delivering planned trauma care and we are in the process of trying to identify how different units around the country can deliver this and network it to the general system itself.” 

He said work was underway on how to better link rehabilitation services into the wider trauma system and on developing lists of trauma-related education and training opportunities in Ireland and abroad. 

Governance 

On the issue of governance, Mr Synnott said individual facilities will remain under the same governance structures that exist currently. 

“The national office for trauma services won’t have a role in telling any hospital what it should or shouldn’t be doing,” he said. 

However, the Clinical Lead added that the office would “try to provide some governance structure over the integrated piece, the networked elements of the trauma system”. 

This would be to ensure that patients are sent “to the places they need to be for treatment”. 

He emphasised that the two major trauma centres (MTCs) are crucial to the plan. 

In April 2021, the Government announced the designation of the Mater Misericordiae University Hospital, Dublin, as the MTC for the central trauma network. Cork University Hospital (CUH) had already been identified as the MTC for the south trauma network. 

Mr Synnott described the MTCs as the “big change” in the new system. “If you have MTCs, you have a trauma system,” he said. 

“We are very much hopeful that there will be major trauma centres in Ireland by the end of the year, albeit with reduced capacity of what we will ultimately envisage.” 

The Clinical Lead noted that “there’s lots of enabling pieces, there is lots of work to be done to enable the system to [be] what we want it to be, and we know it is going to take five-to-seven years” 

“We planned what we want to do and now it’s time to get going. It’s time to start doing things.” 

Development of clinical pathway for head injuries 

In Dublin, clinical representatives from Beaumont Hospital and the Mater Misericordiae University Hospital are currently working “in collaboration to develop a proposed clinical pathway” for patients with head injuries, the Medical Independent (MI) has been informed. 

As reported in MI in August 2021, the decision to designate the Mater Hospital as the MTC for the central trauma network led to criticism regarding neurosurgery provision. At the time, neurosurgeons in Beaumont Hospital, where the national neurosurgical centre is located, said they believed the national neurosurgical centre needed to be co-located with the MTC. 

Earlier this year, MI reported that an advisory group on this issue had been established and it had recently reported to the Executive. This neuro-trauma clinical advisory group (CAG) has been established to work through detailed service considerations to enable an integrated model of care for neurotrauma/neurocritical care services for the MTC in Dublin as a collaboration between the Mater Hospital and Beaumont Hospital. 

Regarding the CAG’s recent report to the HSE, an Executive spokesperson told this newspaper that “clinical representatives from Beaumont Hospital and the Mater Hospital are working in collaboration to develop a proposed clinical pathway for head-injured patients following the recent presentation on its work to the HSE’s trauma programme steering group”. 

“These pathways will develop further as services commence at the major trauma centre.” 

Mater Hospital 

Mr Synnott said that Mater Hospital had expected to be receiving major trauma patients from other hospitals in October. However, due to the need for extra beds, this will not be delivered “until towards the end of the year”. 

However, in early 2023, the hospital will have the ability to accept patients by-passed from other areas in Dublin, “initially on the northside and hopefully then on the southside”. 

“This will be the biggest change in the system and ultimately the Mater will see the biggest increase in the volume of patients and this change will necessarily be incremental. It won’t be all switched on at once.” 

With the MTC in Cork, Mr Synnott said that “again we are hoping by the end of the year to commence major trauma services”. 

He said CUH was different as it “has been delivering these services for patients in this area for quite a long time”. 

“But to try and homogenise and standardise what is available, there is a lot of work being done to try and refine the process.” He said this will require both human and infrastructural resources to be put in place, noting that the “infrastructural challenges are not minor and need quite a bit of addressing”. 

“Again, by the end of 2022 [and] ready for launch in 2023, there will be a major trauma centre [in Cork], albeit not to the full capacity that we would envisage ultimately.” 

Mr Synnott said funding was secured for recruitment and this process was underway. He added that, later in the year, the HSE plans to organise a recruitment fair “that recognises the challenges across the system in recruiting people [and] to try to identify opportunities maybe for people to come to Ireland and work”. 

“We do think the trauma system as we envisage it being [will be] an attractive place for people to work. So that will allow us to try and attract people back to fill some of the gaps that we have identified that are present.” 

Recruitment 

The hiring of consultants and other medical staff for the new trauma service takes place against an international recruitment situation, which the HSE officially describes as “challenging”. In August, MI reported that the Executive was developing a new recruitment strategic programme in response to “operating in a very competitive global recruitment market”. 

Separately, the IMO and IHCA are currently in negotiations with the Department and the HSE in regards to a new consultant contract. A successful conclusion to these talks is regarded by many as key to tackling recruitment and retention issues in the health system. 

In August, MI reported that two consultant appointments had been made for the new MTC at the Mater and annual funding to appoint 17 consultants for the MTC had been secured. 

In updated recruitment figures supplied to this newspaper, the HSE said four consultant appointments have now been made, with an additional six expected to commence shortly. A further three are at an advanced stage of the recruitment process. 

In Munster, the HSE said it had provided annual funding to appoint 13 consultants for the MTC at CUH for stage one of a three-stage implementation plan to deliver a fully functional MTC over the next seven years. 

“Recruitment of consultant and other key clinical and support staff required to commence major trauma services at the MTC in Cork is underway,” the spokesperson added. 

While the two MTCs may be the most important hubs of the new national trauma service, further recruitment of consultants and other medical personnel will be required in other sites. 

The national office for trauma services is currently working with hospitals in other geographical locations outside of the Mater and CUH to undertake a trauma unit accreditation process. The office “when planning the development of the trauma system, will consider additional consultant and other key clinical and support staff requirements for hospitals in other geographical locations”, said the spokesperson. 

“A case will be made through the normal service planning mechanism in the coming years to support the additional resource requirements.” 

Contract 

Difficulties in the recruitment of consultants, as well as beds capacity and equipment issues, are a barrier to the implementation of the trauma strategy, the IHCA told this newspaper. 

Mr Martin Varley 

“With over 900 permanent hospital consultant posts now vacant or not filled as needed, our ability to implement and deliver on health service plans will continue to be severely hampered,” IHCA Secretary General Mr Martin Varley told MI

“There are simply not the required number of consultants needed to provide timely, essential care – this includes specific services such as trauma care.” 

Mr Varley said that the continuing negotiations between the Association and health service management on a new consultant contract was a “critical element”. 

The new contract would need to ensure that “we address the current barriers to recruitment and retention, so that we can attract the number and calibre of consultants who are so urgently required”. 

“In addition, Government needs to ensure funding for and delivery of the essential resources and capacity associated with the implementation of services like the major trauma service. 

“Without the beds, staffing and equipment required, these services risk being seriously undermined to the detriment of our patients.” 

IMO consultant committee Chair Prof Matthew Sadlier also believes that a new consultant contract that is attractive to doctors would have a positive impact on recruitment and retention. 

“Certainly it can improve recruitment, and certainly if you reverse the 2012 pay cut that would improve recruitment to a certain extent,” Prof Sadlier, Consultant Psychiatrist and Clinical Director, North Dublin, told MI

However, he cautioned that even with a new contract, it would most likely take time before consultants were attracted in sufficient numbers to the Irish health service. 

“Because are all the problems to do with pay? No. Are all problems to do with terms and conditions? No.” 

Prof Matthew Sadlier

Capacity 

Prof Sadlier highlighted issues with bed capacity in hospitals and other infrastructural problems, such as surgeons not having sufficient theatre access. 

He also referred to doctors “who can’t do elective surgery because there is a flu outbreak and all our [hospital] beds are gone”. 

“Terms and conditions [of employment] is an issue, but the other is service provision. We are talking about the environment that people are working in and the service they can provide to their patients, that will take time to improve.” 

Speaking on health policies in general, Prof Sadlier said that recruitment challenges were not always taken into account. 

“There is not enough conversation [during the formation of health policy] with the main stakeholders, with staff, and I think there is a bit too much ‘blue sky thinking’ and engagement with theoretical ideas. There’s a bit too much theoretical health policy without enough talking to people who are working in the real world.” 

Noting the Government’s recent announcement of plans to appoint almost 50 new emergency department consultants, Prof Sadlier said it was to be welcomed. 

However, he said there needed to be planning around how to increase the number of doctors coming through the training system “and that takes years”. 

Prof Sadlier said there needed to be discussion around possible fast-track training, “more engagement with the colleges” and other stakeholders, “rather than recruitment by press release.” 

“In general, there is a huge problem with knee-jerk Government decision-making without joined-up thinking,” according to Prof Sadlier. 

The Covid-19 pandemic and trauma 

Falls in homes accounted for most major trauma injuries during the period 2019/20, according to the Major Trauma Audit Report 2019-2020, published last month. 

The report looked at patients who had suffered a major trauma accident over the course of 2019 and 2020, with a focus on the early impact of the Covid-19 pandemic on trauma activity and care. 

“The publication of this report presents the first picture of how trauma activity, care, and outcomes were affected during a very tumultuous time in the health service due to the pandemic,” said Prof Conor Deasy, Clinical Lead for the Major Trauma Audit (MTA). “The significance of this data can help to inform future public health strategies and the reconfiguration of the trauma system when such events like a pandemic or cyberattack occur.” 

Ms Louise Brent, Audit Manager for the MTA, added: “The increase of falls in the home over the course of the first three waves of the pandemic shows us that there is a real opportunity for the public to use this information to ensure their homes are as safe as possible.” 

“Using the data on falls in the home we have designed a very quick checklist that anyone can use to identify common causes and risks that may be present in the home, the majority of which are easily remedied. Ireland has achieved a lot of improvement in the likes of road safety. We now must turn our attention to home safety as well.” 

Some findings from the report include: 

  • The mean age of major trauma patients increased from 58 years in 2019 to 61 years in 2020. 
  • The percentage of falls of less than two metres increased from 58 per cent in 2019 to 62 per cent in 2020. 
  • The proportion of patients injured at home increased from 48 per cent in 2019 to 56 per cent in 2020. 
  • There was an approximately 10 per cent reduction in the number of major trauma admissions during 2020, compared with 2019. 

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