Almost all of the evidence of the effectiveness of improvements in the organization of trauma care services comes from developed countries. In most cases, the better organization comes in the form of two related activities: (1) verification of trauma services through hospital inspections; and (2) planning of systems for trauma management. Verification applies to a review of individual facilities as regards their provision of a variety of items, including human resources (e.g. availability of personnel with certain qualifications), physical resources (equipment and supplies) and administrative and organizational functions, such as quality improvement. The planning of systems for trauma management implies several integrated functions, including political jurisdictions designating which hospitals are to fill the roles of trauma centres at varying levels of complexity, ranging from large urban trauma centres to small rural hospitals and clinics. It also implies the planning of mobile emergency medical services, pre-hospital triage (to determine which patients should go to which types of designated facilities), transfer criteria and transfer arrangements between hospitals.
There is considerable evidence that political jurisdictions that improve the organization of trauma services benefit from reduced trauma mortality, in comparison with similarly resourced jurisdictions that do not. Such evidence comes from panel reviews of preventable deaths, hospital trauma registry studies and population-based studies (7, 22, 23). Most studies confirm a reduction in mortality with the improved organization provided by a system for trauma management. For example, panel reviews show an average reduction in medically preventable deaths of 50% after the implementation of a system for trauma management. Likewise, population-based studies and trauma registry studies show a fairly consistent 15-20% or greater reduction in mortality for better organized systems, compared with either the same systems prior to improvements in organization or to other less organized systems (6, 7, 23).
In one of the best series of studies done on this topic, Nathens et al. used population-based data to examine the effects of planning of systems for trauma management in all of the 50 states of the United States. They looked at mortality rates, adjusting for several potential confounding variables, including traffic laws and other safety measures. They demonstrated an 8% reduction in mortality for those states with systems for trauma management. It should be mentioned that this figure represents overall trauma mortality, including persons dead at the scene, before any chance of medical treatment. In comparison, the larger reductions in mortality mentioned above represented changes in mortality for patients surviving to reach the hospital. Especially notable in Nathens' study was the finding that the effect of a system for trauma management was not usually evident until 10 years after its initial enactment and reached a maximum at 16 years (8, 9).
When considering the relevance of these findings to the potential utility of similar organizational efforts in developing countries, it is important to note that the above improvements were mostly witnessed in comparison with environments with the same levels of resources. The enactment of an organized system for trauma management usually required inputs of resources that were fairly small in comparison with the overall cost of the existing system of care itself. The system for trauma management itself did require the funds for increased organization and occasional extra inputs of resources to bring institutions up to standards for verification (6). The Essential Trauma Care Project is based on making similar improvements in organization and planning that are inexpensive in comparison with the cost of the existing treatment system itself.
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