Maturation of trauma systems in Europe

A well-functioning and well-developed trauma system is critical for improving patient survival and outcome. The results of this self-assessment survey show that the overall trauma system maturity score for the European countries varied between 28.2 and 48.0 points on a scale from 19 to 50 points. This reflects that the variation in the level of development of trauma care systems in Europe is substantial, with countries in Northern Europe evaluating their trauma system development significantly higher than countries in Southern Europe, suggesting a geographical gap in the degree of trauma system maturity. Furthermore, variation in maturity between elements of trauma care was also observed within countries, with most countries evaluating their prehospital care as well developed and their quality assurance as least developed.

The need to understand and value trauma systems has been long called for. Trauma remains one of the leading causes of death worldwide, and the most common cause of death in Europeans younger than 40 [5]. Lessons from the World Wars [15, 16], the polio epidemic [17], and the coronavirus pandemic [18] have stressed the value of a well-developed and well-organized healthcare system, including the presence of a mature trauma system to reduce mortality. Yet, as stated by the International Orthopaedic Trauma Association in 2019, “while the interest in developing trauma care is growing, the overall adoption is low” [19].

Disparities in the degree of trauma system maturation in Europe have previously been demonstrated [2, 3, 20, 21]. A previous self-assessment in 2008 showed that central European countries with ties to the Austro-German surgical tradition (Germany, Austria, Switzerland, the Netherlands, Czechia, Slovakia, Hungary, and Slovenia) rated their trauma systems as advanced in terms of trauma system development and trauma surgery specialization [2]. However, by 2017, this difference was no longer significant, as other countries have also improved in the domains of trauma surgery specialization and overall trauma system development [3]. It has been proposed that the pace at which trauma systems in a country develop and are organized is largely determined by the occurrence of national disasters, or by its most pressing national healthcare challenge [17]. For example, changes to the trauma system in the Netherlands were initiated after a devastating plane crash that highlighted the lack of organization between prehospital and in-hospital care, while improvement of the Spanish trauma system was motivated by the increase in road traffic accidents [21].

Each country faces its own challenges with regard to trauma system implementation. While some trauma systems must provide trauma care to highly densely populated areas, others rely on helicopter transport to cope with long distances and environmental inaccessibility [20]. Aside from geographical region variations, trauma system maturity and design may also differ substantially between similar geographical regions. One example concerns the Netherlands and Belgium. In agreement with a 2003 study [22], Belgian surgeons evaluated their trauma system as being less mature than that in the Netherlands. Although advancements have been made since 2003 [3], surgeons still report that there are no set criteria for trauma care levels, that trauma surgery is not a specialization, and that quality assurance is not implemented. Another example is differences in trauma system maturity between the Nordic countries. Although trauma surgery is not recognized as an independent specialization in any of the Nordic countries, variation in trauma systems has been observed among the individual countries. Consistent with previous findings [23, 24], Norwegian trauma systems have the highest level of trauma system maturity, owing to the availability of funding programs for research and the implementation of a trauma team training program. While both Finland and Sweden lack a lead agency to oversee the trauma system and research funding, evidence suggests that trauma care is less developed in Finland, as only 20% of trauma-receiving hospitals have trauma teams [20].

Aside from regional and geographical challenges, several generic challenges can be distinguished with regard to the development of trauma systems in Europe. First, despite recommendations and guidelines, the enforcement of trauma education and training is valued suboptimal by most participating countries. While proper education and training are also paramount for a well-functioning trauma system, our survey results suggest that trauma education is not considered equally important as prehospital and in-hospital care. Perpetuating factors in this issue include lack of funding, lack of resources, lack of interest [20], and the absence of quality control audits [25]. Second, the absence of a lead agency and quality assurance programs hinders progression. According to the Trauma Systems Agenda for the Future, the fragmentation of trauma leadership is a major impediment to the development of a national trauma system [13]. An advantage of having a clear lead agency is that it can advise the government on the development of their trauma system and to provide support. The lack of a lead agency would be challenging to maintain a national overview and would have consequences for funding and research. Third, the need to define and appoint trauma centers is still unfulfilled in several countries. Politics and economics aside, a contributing factor to this matter is the lack of recognition of trauma surgery as a separate specialization. Although the need for a trauma surgery subspecialty might seem trivial for countries that lack funding, facilities, human resources or a mature trauma system, it has been demonstrated that having dedicated trauma surgeons benefit patient safety and quality of care [26]. Additionally, dedicated trauma surgeons may also serve as ambassadors of public safety by raising awareness through research and prevention programs [27, 28]. Regarding the appointment of dedicated trauma centers, evidence suggests that severely injured patients—specifically those with head injury, thorax injury, or signs of shock—benefit from direct transport to a Level 1 trauma center [29,30,31]. Keeping in mind that trauma causes a high burden of death and disability, it is strongly recommended for countries to strive to implement a classification system for trauma care levels.

Limitations

Due to the study design, a substantial response bias cannot be ruled out. The scores presented in this study reflect a subjective evaluation, and the experience and knowledge of selected surgeons with regard to their country’s trauma system. Therefore, the accuracy of the presented trauma systems evaluation cannot be guaranteed, and the results for individual countries should be interpreted with caution. Additionally, there is sampling bias. We tried to minimize this bias by approaching surgeons from different hospitals. However, due to the anonymous nature of the survey, this cannot be guaranteed. Furthermore, considering that the survey was sent electronically via email, it cannot be ruled out that other people than those intended filled out the survey. Moreover, the number of respondents differed between countries, ranging from two to ten, which could have led to an under- or over-estimation of end scores as lower numbers of respondents, more reflect subjective insights. Lastly, the survey email itself received criticism as it caused confusion surrounding the definition of “trauma surgeon,” as trauma surgery is not always regarded as a separate specialty in selected countries. It is unclear whether this played a role in limiting the number of participating countries or influenced the results in any way. Nevertheless, this survey is the first since a long time to provide an, albeit subjective, impression of the maturation of trauma systems throughout Europe, and as such provides a basis for further improvement and future research on quality of trauma system care.

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