The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands

Following concerns about the organization of both pre-hospital and in-hospital trauma care and the increased public awareness about the importance of well-organized acute care [1, 2], the Dutch government appointed ten trauma centers (TC) in 1998 [3, 4]. Currently, the Dutch trauma care is organized in eleven trauma regions and resembles the American trauma system based on the criteria set by the American College of Surgeons Committee on Trauma [5]. Each region has a catchment area of at least 1.2 million inhabitants with one coordinating TC and several non-trauma centers (NTC) in every region. Since the introduction of the regionalized trauma care, several quality measures were deployed, such as a mandatory participation in the Dutch Trauma Registry [DTR] (2008), which led to 100% participation by all emergency departments in the registry in 2015. Also, level criteria for trauma- and non-trauma centers (2013), and certification for trauma surgeons were implemented. In 2010, ten years after the introduction of well-organized trauma systems, the overall mortality risk after trauma was found to be reduced by 16% [6]. In the past decade, further development of trauma care in the Netherlands concerned, amongst others, the regionalization of the ambulance care including an update of the national guideline for emergency medical service providers (2011), 24/7 availability of helicopter emergency services (HEMS) for acute trauma (2011), yearly quality reports by the Dutch Trauma Registry (2012) and the introduction of trauma-related quality indicators by the Dutch government (2015) (Fig. 1).

Twenty years after the introduction of trauma systems in the Netherlands knowledge about parameters that may influence the distribution of trauma patients is relevant, per se and as a prelude to the analysis of the clinical effects of this concentration of care over time. The objective of this study is to describe the impact of structured trauma care on the distribution of severely injured patients between trauma centers (TC) and non-trauma centers (NTC).

Over the period 2008–2018, the centralization of trauma care in the Netherlands continued. The total number of registered severely injured patients has increased to annually about 4500. This increase is at least partly attributable to increased participation of NTCs in the DTR and to a more accurate registration. As of 2014, all TCs and NTCs with an ED participated in the registry and from then on representative data was available. The proportion of the severely injured patients who were directly brought to a TC slightly increased, and stabilized at 70% in the most recent years. This proportion was somewhat higher for the severely injured patients with severe neurotrauma than for those without neurotrauma or only mild or moderate neurotrauma. The injury severity within the group of severely injured patients that were directly brought to a TC has increased since 2014, especially in the subgroup of patients with severe neurotrauma.

Despite many improvements, challenges remain to be faced. As a consequence of the introduction of a trauma system, severely injured patients are more likely to be admitted to a TC than in the 1990s [6]. However, about 30% of these patients are still transported to NTCs in the Netherlands. Similar percentages are seen in other countries, such as Norway and the United States [17‐21]. According to the American College of Surgeons Committee on Trauma, an under-triage rate above 5% is unacceptable, as under-triage increases the risk of mortality and morbidity due to patients not being managed at the best-equipped hospital [22]. In addition, MacKenzie et al. showed in their study that, especially for the younger, more severely injured patients, treatment at a TC is not only more effective but also cost-effective, which underlines the importance of bringing the severely injured to a TC [23]. Studies show that especially the most severely injured patients, with ISS ≥ 25, hemodynamically instable and patients with severe traumatic brain injury (AIS ≥ 3), benefit the most from proper hospital triage, demonstrating lower mortality rates for these patients when brought to a TC [24‐27]. Reducing under-triage should therefore be given priority. This does, however, remain a major challenge even in mature trauma systems [22, 28]. Van Rein et al. showed in their systematic review that almost all pre-hospital triage protocols had a low sensitivity and therefore failed to identify all severely injured patients who needed treatment in a TC [29]. Especially identifying serious neurotrauma by EMS providers has proven to be difficult; 32% of all neurotrauma and 21% of the severe neurotrauma are not recognized at the accident scene [30]. Particularly for these patients, the hospital triage may be further optimized by advanced triage tools. In trauma patients, the effects of drugs and alcohol often obscure the real trauma-related neurological symptoms so that symptoms often do not correspond with findings on the CT scans once the patients have arrived at the ED [30].

The current lack of field triage criteria able to adequately predict if a patient will be classified as severely injured contributes to the challenge to fulfill the Dutch Healthcare Institute’s prerequisite of 90% severely injured patients being brought directly to a dedicated TC. In practice, emergency service providers guide their decision whether or not to go to a TC based on their clinical experience, and clinical signs of severe injury at the accident scene in addition to what the ambulance protocols prescribe [31]. Future research should focus on developing tools for scientifically substantiated assistance in this decision-making and improve the quality of pre-hospital triage in severely injured patients [32, 33].

Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being brought directly to a TC. The injury severity within the group of severely injured patients that are directly transported to a TC has increased slightly in the most recent years, especially in the subgroup of patients with severe neurotrauma. However, still 30% of all severely injured patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.