Trauma is one of the leading causes of death and disability—with injuries accounting for 9% of global mortality—and has an enormous worldwide impact on health.1 Preventing and decreasing the burden of trauma are among the chief challenges for public health agencies around the world. Development of a trauma system able to accurately measure the incidence, process of care and outcomes of traumatic injuries—while getting the right patients to the right hospitals at the right time in an organized and coordinated way—is paramount.
Recently, South Korea set a goal to develop such a system. In 2012, this vital task was assigned by the government to experts from multiple disciplines of trauma care working with the Korean Society of Traumatology (KST). One of the first actions of these chosen leaders was to visit existing trauma systems in the United States to gather information about trauma system development.
Trauma in South Korea
The population of South Korea is approximately 51 million,2 and the country has the third highest population density in the world for countries having over 10 million people.3 Trauma is the third most common cause of death in South Korea and the leading cause of death for those younger than 45 years old.4 The mortality rate from injury is 60.8 per 100,000 people—higher than North America (53/100,000), the U.K. (25/100,000), Germany (25/100,000), Sweden (32/100,000), Japan (36/100,000) and Singapore (21/100,000).5 Alarmingly, the preventable death rate from traumatic injury was 35.2% in 2010, as reported by the Korean government.6 This preventable death rate is very high compared to previous reports from some U.S. states.7,8
Additionally, due to high regional political tensions, particularly with North Korea, South Korean leaders see the need for a highly functional emergency preparedness and mass casualty care system. These factors have caused an increased urgency in the development of a formal trauma care system in South Korea.
In 2013, as part of an effort to develop a comprehensive, nationwide trauma system, the Korean Ministry of Health and Welfare designated eight hospitals as regional trauma centers, with plans to eventually designate a total of 17 hospitals as regional trauma centers (including two free-standing trauma centers) by 2016.
Another main goal is to set up trauma care system monitoring to evaluate the components of the system and provide feedback to communities, EMS and hospitals. The Korea Centers for Disease Control and Prevention and the National Fire Service collaborated to develop a nationwide trauma registry that has been monitoring the trauma care system since 2011. The registry includes information on all severe trauma patients transported by ambulance services using the revised trauma score. Hospital records are reviewed to obtain hospital outcomes (mortality and disability) and to assess hospital performance (ED, surgical and intensive care processes). The nationwide registry is planned to be fully developed by 2015.
Trauma in the U.S.
As in South Korea, trauma is a leading cause of death in the U.S.9 (population: 313.9 million10). The population of Arizona is 6.5 million,11 representing approximately 2% of the entire U.S. Outside of the urban areas of Phoenix and Tucson, Arizon is a largely rural state, but the incidence of trauma in Arizona is comparable with other states in the country.12,13
Two key steps have been taken to address this public health problem and strengthen Arizona’s statewide trauma system. In 2007, Arizona underwent its first American College of Surgeons Committee on Trauma (ACS COT) state trauma system consultation. Due to several factors, including a large population growth in the state, Arizona’s trauma system has grown rapidly (from eight Level 1 trauma centers and no Level 2, 3, or 4 centers to 32 trauma centers—eight are Level 1, three are Level 3, and 21 are Level 4—and an additional 17 non-level trauma centers serving rural areas).
In November 2012, Arizona underwent a second ACS COT system-wide trauma review that further advanced and strengthened the Arizona Trauma System to ensure the best quality care for trauma victims.
Trauma System Development
A trauma system is a preplanned, organized and coordinated response to managing treatment of severely injured people and covers the full spectrum from prevention and emergency care to recovery and rehabilitation. The goal of a regional or national trauma system is to measure and reduce the incidence and severity of injury, as well as to improve health outcomes for the injured.
Prehospital trauma care has a significant impact on survival. The basic concept is if the initial patient triage, treatment and appropriate transport (both level and destination) of the severely injured patient aren’t done properly, the ultimate patient outcome—despite the most sophisticated, state-of-the-art trauma center—won’t be optimized. In other words, the prehospital phase of a trauma system must be seamless, integrated, and carefully implemented and measured.
A trauma system must ensure prompt access to care, starting with the dispatch of the correct level of prehospital providers who are intimately familiar with the operations, resources and capabilities of their trauma system. The fundamental aspect of the prehospital phase of trauma care involves the rapid assessment and stabilization of the most life-threatening injuries first (addressing a patient’s airway, controlling hemorrhage, treating shock in the appropriate situations, and stabilizing limb-threatening injuries) as well as rapid and safe transport of patients to the closest appropriate facility (such as a neuro-trauma center for severely brain injured patients or pediatric trauma center for injured children).
Prehospital providers are an integral part of a structured, well-coordinated regional trauma system. This trauma system must be supported by an emergency communication system that provides immediate citizen access along with pre-arrival instructions for callers. Clear communications, including the age, vital signs, and severity and description of injuries, between both prehospital providers and receiving facilities are fundamental. This allows assembling the trauma team within the trauma center and having all necessary lifesaving treatments (i.e., intubation devices, IV or intraosseous access devices, blood products, etc.) ready.
EMS protocols should include medical direction on prehospital triage, treatment and transport. Although most trauma systems in the U.S. currently use the Centers for Disease Control and Prevention’s “Guidelines for Field Triage of the Injured Patient,”14 some systems use a version customized to their trauma system. An accurate and effective prehospital data collection system needs to be established for continuity of care along with continuous performance measurement and quality improvement.
Trauma center accreditation and the criteria for the establishment of a regional trauma system was first published by ACS COT in 197615 and has had a tremendous impact on standardizing and improving care of trauma patients.16
In the U.S., trauma centers are designated Level 1 to 4, depending on their capabilities. Level 1 trauma centers are tertiary care hospitals that demonstrate a leadership role in system development, optimal trauma care, quality assurance, education and research. Level 1 trauma centers address public education and prevention issues and provide education for all levels of trauma care providers.
Level 2 and 3 trauma centers are usually large community hospitals, and Level 4 trauma centers are typically smaller hospitals often located in rural areas. Non-level trauma centers are expected to provide initial evaluation, resuscitation and stabilization of patients.
Transfer agreements and protocols must be in place between trauma centers. According to a recent study using prospectively collected data, the risk of death from severe traumatic injury is significantly lower when care is provided in a trauma center than in a non-trauma center.17
Inclusive trauma systems are another important aspect of a comprehensive system. The concept of the inclusive trauma care system derived from the idea that trauma care should be community-based rather than trauma center-based and planned for all populations and situations, incorporating the unique needs of children, the elderly, burn victims, victims of natural and manmade disasters, and those with cultural considerations.
Trauma Registry & Measurement of Performance
The age-old adage, “If you can’t measure it, you can’t improve it,” applies directly to trauma care. A trauma system has to measure and monitor its performance and use the data for quality assurance and improvement. Ongoing accurate data collection and analysis with a system-wide trauma registry are fundamental. (See Figure 1: The injury pyramid illustration, courtesy of World Health Organization–attached.)
The regional trauma registry or information system should be designed to provide system-wide data that facilitate evaluation of the structure, process and outcomes of the entire system—all phases of care including injury prevention, prehospital, hospital, trauma center, rehabilitation facilities and their interactions.
Korea-Arizona Trauma Summit
During the past several years, an international partnership has been forged between the Arizona Trauma System and the KST. Although on different sides of the globe, both organizations are committed to improving trauma care and outcomes, and each wants to utilize a systematic approach to trauma system implementation and measurement that uses the latest tools, such as electronic data capture and comprehensive trauma registries. Because of these similar objectives and strategies, Arizona’s system was selected as a model by the South Korean government.
Another reason the Arizona Trauma System was both attractive and pertinent to the KST was that Arizona’s trauma system is relatively new (less than 15 years old), evolving rapidly, and focused on the latest trauma treatment guidelines as well as novel trauma care interventions. This partnership began in 2012 when the South Korean government dispatched on several occasions public health officials, clinicians and researchers to work with the Bureau of EMS & Trauma System at the Arizona Department of Health Services.
The largest meeting between the South Korean government and the Arizona Trauma System was the Korea-Arizona Trauma Summit (KATS) that took place in Phoenix and Tucson, April 1–4, 2013. KATS was hosted by the Ramsey Social Justice Foundation (RSJF), which provides grants and financial assistance to underrepresented communities and EMS systems globally, as well as support of international health care projects, such as CPR Link to Life. In collaboration with the Arizona Department of Health Services, RSJF brought together leaders in Arizona EMS; trauma, neuro and orthopedic surgery; emergency medicine; pediatrics; natural and manmade disaster response; nursing; trauma prevention; hospital administration; public health; and influential politicians to discuss how to best implement and measure coordinated state-of-the-art trauma systems.
The 2013 KATS delegation was comprised of 36 delegates including Chairman of the Health and Welfare Committee for the Republic of Korea Oh Jae Sae; Director General of Public Health Policy from the Ministry of Health and Welfare Woo Jin Jung; and President of the National Medical Center Yeo Gyu Youn. On the U.S. side was Director of Public Health for Arizona Will Humble; Dean of the University of Arizona College of Medicine Phoenix Campus Stuart Flynn, MD; Phoenix Mayor Greg Stanton; U.S. Rep. Ed Pastor; and Arizona Governor Jan Brewer.
Over a four-day period, the group met with numerous Arizona government (state, county and city) officials and trauma experts at several of Arizona’s trauma centers to discuss state-of-the-art trauma care across multiple disciplines, as well as other various topics including prevention, EMS training, pediatric trauma care, data collection and research. Meetings were held with Korean and Arizona EMS leaders discussing optimal prehospital trauma care, trauma triage and transport guidelines, use of emergency ultrasound, and the unique NIH-funded statewide prehospital traumatic brain injury study currently underway in the state. Another topic was EMS trauma training using state-of-the-art simulation training demonstrated at the Phoenix campus of the University of Arizona College of Medicine.
The KATS focused on the prime importance of prehospital data collection and linkage with a trauma registry. Examples of the need for a robust system-wide data collection system were given by the Arizona Department of Health Services, Bureau of EMS and Trauma System personnel who presented the Arizona State Trauma Registry and and discussed cutting-edge electronic prehospital care records systems. Effective electronic prehospital data collection and telemedicine systems were demonstrated and discussed, including presentations on the Arizona Telemedicine Network.
Trauma is a major public health problem worldwide. Developing a high-functioning trauma care system that encompasses the entire process of care from injury prevention to rehabilitation, as well as an accurate, integrated data collection system, is fundamental to improving outcomes from traumatic injuries. Through this unique KATS, both KST and Arizona Trauma System leaders now better recognize the importance of inclusive and integrated systems of care and development of state/national data registries that allow continued research and collaboration in how to improve trauma care. This unique trauma summit provided a tremendous cross-cultural experience for both countries and was an excellent example of international partnerships working toward improving emergency medical care and decreasing the massive global burden of trauma.
View more pictures from the Korea-America Trauma Summit at www.katsummit.com
1. World Health Organization Department of Violence and Injury Prevention and Disability. (2013.) Global status report on road safety. Retrieved Nov. 1, 2013, from www.who.int/violence_injury_prevention/road_safety_status/2013.
2. Korea Culture and Information Service. (n.d.) Facts about Korea. Korea.net Gateway to Korea. Retrieved Nov. 1, 2013, from www.korea.net/AboutKorea/Korea-at-a-Glance/Facts-about-Korea.
3. The World Bank Group. (2013.) Population density (people per sq. km of land area). Retrieved Nov. 1, 2013, from http://data.worldbank.org/indicator/en.Pop.Dnst.
4. Statistics Korea. (2012.) Cause of death statistics. Retrieved Nov. 1, 2013, from http://kostat.go.kr/portal/korea/kor_nw/2/6/2/index.board.
5. World Health Organization. (2012.) World health statistics 2012. Retrieved Nov. 1, 2013, from www.who.int/gho/publications/world_health_statistics/2012.
6. Ministry of Health and Welfare. (Oct. 14, 2011.) Patients suffering traumatic injuries to receive intensive care. Retrieved Nov. 1, 2013, from http://english.mw.go.kr/front_eng/cs/scs0401vw.jsp?PAR_MENU_ID=1004&MENU_ID=100406&page=1&CONT_SEQ=259611&tabVal=1365&SEARCHKEY=TITLE&reQuery=&SEARCHVALUE=trauma.
7. Esposito TJ, Sanddal TL, Reynolds SA, et al. Effect of a voluntary trauma system on preventable death and inappropriate care in a rural state. J Trauma. 2003;54(4):663–670.
8. Sanddal TL, Esposito TJ, Whitney JR, et al. Analysis of preventable trauma deaths and opportunities for trauma care improvement in Utah. J Trauma. 2011;70(4):970–977.
9. National Vital Statistics System, National Center for Health Statistics, Centers for Disease Control and Prevention. (2010.) 10 leading causes of death by age group, United States–2010. Retrieved Nov. 5, 2013, from www.cdc.gov/injury/wisqars/pdf/10lcid_all_deaths_by_age_group_2010-a.Pdf.
10. United States Census Bureau. (Jan. 7, 2014.) USA: State and country quick facts. Retrieved Nov. 1, 2013, from http://quickfacts.census.gov/qfd/states/00000.html.
11. United States Census Bureau. (Jan. 6, 2014.) Arizona: State and country quick facts. Retrieved Nov. 1, 2013, from http://quickfacts.census.gov/qfd/states/04000.html.
12. Arizona Department of Health Services. (July 2, 2013.) Advance vital statistics by county of residence. Section 3: Leading causes of death by age group, Arizona, 2012. Retrieved Nov. 1, 2013, from www.azdhs.gov/plan/report/avs/avs12/section%203.htm.
13. Murphy SL, Xu J, Kochanek KD. Deaths: Final data for 2010. Natl Vital Stat Rep. 2013;61(4):1–118.
14. Sasser SM, Hunt RC, Faul M, et al. Guidelines for field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep. 2012;61(RR-1):1–20.
15. American College of Surgeons Committee on Trauma. Optimal hospital resources for care of the seriously injured. Bull Am Coll Surg. 1976;61(9):15–22.
16. DeBritz JN, Pollak AN. The impact of trauma center accreditation on patient outcome. Injury. 2006;37(12):1166–1171.
17. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366–378.