Discussion

This is the first study to examine the maturation of staffing structures in English MTCs. Almost all of the responding MTCs report an annual volume of more than 240 severely injured patients, which is deemed the minimum case volume required for a trauma centre to effect a change in mortality,8 ,9 although it is acknowledged that there is also evidence that the number may be as high as 400 severely injured patients per year, or even 650 severely injured patients per year.10 All of the MTCs have a trauma call procedure, although in one the response is not led by a consultant. This compares favourably with a survey performed in 2008, although this previous study examined all hospitals, rather than MTCs in particular.11

The importance of a dedicated service to care for trauma patients—following their initial assessment and treatment—is increasingly recognised. It is therefore concerning that only just over half of the centres have instituted such a service, although it should be noted that several others are planning to develop a trauma service. Providing a consultant-delivered major trauma service has cost implications, and is difficult to justify when the volume of severely injured patients is low. It is conceivable that a further rationalisation of services may have to be considered in areas where hospitals are unable to provide such a service, although there are other considerations—such as accessibility—which need to be taken into account.

It is also noteworthy that the service models which are emerging differ from those in other parts of the world. At present, only two of the MTCs, both in London, have a trauma service comparable to that of a US trauma centre, comprising surgeons with a general/vascular surgical background. Taking into consideration the additional MTCs with orthopaedic trauma service provision, only 9 of England's 22 MTCs have developed a template that places surgeons at the centre of on-going care for the major trauma patient. The extent to which such models of service have been the result of methodical design, based on local injury patterns and patient need, was not assessed in our survey. We also did not assess the essential competencies required to deliver trauma care, although it is acknowledged that these will be delivered in part by engagement with other specialties.

Different MTCs will have been led by trauma champions from a variety of clinical backgrounds. Emergency medicine physicians in the UK have made major and sustained contributions to acute trauma care, and have been vigorous in developing the emerging specialty of prehospital care. Similarly, other specialties represented on the multidisciplinary rotas—in particular, anaesthesia and critical care medicine—often have considerable experience of managing abnormal physiology, although neither of these specialties have traditionally had continuity of care responsibility. However, trauma-trained surgeons offer advantages to the on-going care of the injured, as continuity of named consultant care is fundamental to British surgical practice, and can thus assure the patient pathway from admission through to discharge and beyond. This is particularly important when, for example, non-operative management is considered; where continual repeat assessment and evaluation is required to change to an interventional approach should the non-operative strategy fail. Furthermore, many of the functions of a trauma service, such as performance improvement, planning discharge arrangements, and ensuring follow-up, are core functions of modern surgical practice.

In addition to addressing the ongoing care of patients who have suffered major trauma, staffing models should also consider the ability of a trauma service to manage the most common preventable cause of death after injury, which is non-compressible torso haemorrhage. The number of patients who present with exsanguinating haemorrhage is small, but decisive and proactive management can profoundly affect outcome. Trauma-trained general surgeons are best placed to diagnose and treat these patients, whether by surgery or through collaboration with interventional radiology services. However, the ability to justify a trauma surgical service—as opposed to a service led by another specialty—partly depends on the volume of such patients, which is related both to overall volume, and to regional case mix. This situation may be less problematic in areas of the UK where penetrating or high-energy blunt trauma is infrequent. However, in those high-volume MTCs catering to populations where surgical intervention is common, this variation in practice raises questions. Furthermore, there are presently very few trauma-trained general surgeons in the UK, and as trauma is not recognised as a general surgical subspecialty, there are no recognised training programmes to equip surgeons who would like to specialise in trauma care with the competencies identified in the most recent 2013 edition of the Intercollegiate Surgical Curriculum.12 In order to rectify the training and experience gap for trauma surgery, there needs to be leadership from the profession to develop the opportunities to gain the necessary competencies and skills.