Trauma Systems. An Era of Development

The introduction of an inclusive trauma system in the Netherlands during last decade of the past century, has led to an improvement in Dutch trauma care. Eleven trauma regions were formed nationwide each surrounding a level I trauma center. All hospitals in a trauma region were assigned levels I, II or III, and are working together in a trauma network. Also part of the introduction of the inclusive trauma system was the regionalization of individual ambulance care and the introduction of mobile medical teams. This regionalized trauma care approach has demonstrated its efficacy in terms of better triage and improved patient outcomes as well in the Netherlands as overseas. An optimal trauma system should at least incorporate legislation, designation, funding, cooperation and research.The best strategy is to prevent the injury from occurring in the first place. But when injury does occur the delivery of optimal trauma care represents a critical tertiary prevention strategy to prevent unnecessary death and disability. The trauma system should be a learning system framework for continual improvement in trauma care. Despite these improvements in trauma care and trauma outcome, trauma still is a leading cause of death in the western world. Every day, 16,000 people die from injuries and for every person who dies, several thousand more are injured, many of them with permanent sequelae. Surprisingly, the public appears generally to be unaware that trauma is the leading cause of death for people under the age of 46. In the Netherlands trauma is associated with an economic cost of €3.5 billion annually, €2.0 billion due to healthcare costs and €1.5 billion due to loss of productivity. In the USA trauma is the number one cause of years of potential life lost before the age of 75. This loss is even greater than the loss due to either cancer or heart disease. Every year approximately 85,000 patients are acutely admitted to hospital because of a trauma in the Netherlands, this is far more than the yearly number of acute admissions due to heart disease. Of these approximately 85,000 patients, about 6,000 patients are multiple injured (ISS ≥16) and 2,000 are severely injured (ISS ≥25). For the first time since the 1970’s there has been an increase in traffic fatalities and the number of patients injured in traffic is growing since at least 15 years. Despite these facts the Netherlands, as most western countries, seems to have a blind spot for this trauma epidemic. This thesis has focused on several aspects of the trauma system, this to gain knowledge on how the different trauma system structures influence patient outcomes. The research was performed in two level I trauma centers and their trauma regions in the Netherlands, the University Medical Center Utrecht (UMCU) in Utrecht and the Elisabeth-TweeSteden Hospital (ETZ) in Tilburg. Furthermore, an international comparison was performed in a collaboration between the UMCU, the John Hunter Hospital (JHH), Newcastle, New South Wales, Australia, and the Harborview Medical Center (HMC), Seattle, Washington, the United States of America