As noted in the American College of Surgeons “Resources for Optimal Care of the Injured Patient” (6th edition, 2014) [16], the trauma system should contain different parts and functions to run and maintain optimal trauma care, including trauma centers, pre-hospital care, inter-hospital transfer, trauma organization and trauma programs, subspecialty trauma care capabilities (e.g., general surgery, emergency medicine, neurosurgery, orthopedic surgery, etc.), pediatric trauma care, multidisciplinary trauma collaboration, rehabilitation, rural trauma care, burn services, trauma registries, performance improvement and patient safety programs, trauma education, prevention, trauma research, trauma academic organization and activities, organ donation programs, and trauma center verification programs. The development of trauma centers and trauma systems in China is still in its early stages and there is much to be learned from the international community, particularly experiences from the United States. Despite the differences in economic situations and social policies between the United States and China, the concepts and components of the trauma system should be very much the same. In the past few years, China has made some major milestones in trauma medicine, including the establishment of the Chinese Medical Doctor Association Committee on Trauma in November 2014, the establishment and propagation of the China Trauma Care Training (CTCT®) since July 2016, the publication of the National Trauma System Development Guideline by the China’s National Health Commission in June 2018, and appointment of the National Center for Trauma Medicine by the National Health Commission in August 2019. Prof. Wang Zhengguo, Prof. Fu Xiaobing, Prof. Jiang Baoguo and Prof. Zhang Lianyang are the most important and absolutely top trauma leaders in China, who have significantly and incredibly contributed to the country.
Prof. Maier and his colleagues found that the effect of regionalization on mortality from motor vehicle accidents reduced the risk of death by 8%, but it took over 10 years for this to manifest itself. Although it is likely that a gradual process of quality improvement was observed, significant reductions in trauma-related mortality were not measurable until several years after implementation of the trauma system [17]. The great ambitious goal of the United States since April 2017 has been to establish a national trauma system and achieve zero preventable trauma deaths nationwide [18-19].Based on the experiences of the American College of Surgeons Committee on Trauma – Trauma Verification Program, our next step to establish a national trauma center verification program in China. In recent years, several Chinese provinces have established their own trauma center development policies. In September 2016, China Trauma Rescue and Treatment Association (CTRTA) was founded and has since established a trauma center development program across China. In the year 2020, CTRTA became one of the components of the National Center for Trauma Medicine (NCTM) located in Peking University People’s Hospital in Beijing. As mentioned above, NCTM was founded by China’s National Health Commission [20] to lead the development of a national trauma center, trauma system, and trauma science. Ideally and undoubtedly, NCTM will become the appropriate organization to establish a nationwide trauma center verification program.
Trauma training is the foundation for trauma care. ATLS® has been developed by the ACS COT for over 40 years and has driven the development of trauma science worldwide. One of the most important characteristics of the ATLS® course is its strict and high quality teaching. The small class, usually 16 students per class, is the standard arrangement. In the past decade, trauma training has been in high demand in China, and ATLS® was not introduced in mainland China until September 2016, so China has developed its own trauma course, “China Trauma Care Training (CTCT®)”, to provide the necessary trauma knowledge and skills training for medical and nursing personnel who take care of trauma patients. As mentioned above, ATLS® was introduced to mainland China in September 2016, and a total of 205 providers have received training from the author’s institution. Looking to the future, the CTCT® and ATLS® courses will assume primary responsibility for providing trauma care training to medical and nursing personnel in mainland China. As stated by Prof. John Wong, “...perhaps, those who wish to receive local trauma training using CTCT®, and those who wish to receive the international standard trauma care course using ATLS®…” In the author’s institution, the mortality rate patients with major trauma in 2019 was significantly lower than that in 2018, which was mainly due to the organization of the multidisciplinary trauma team and the formal establishment of the trauma center in November 2018. All trauma team members received ATLS® training and the ATLS® “common language” was adopted as an early management principle. The timely response of the trauma team and the well-organized trauma resuscitation and following definitive care play a major role for the improvement of trauma quality.
Geospatial analysis has been widely used in the field of trauma for the development of trauma systems internationally [21-25]. Such studies can identify the distribution characteristics of trauma incidents in a particular region or country, as well as the distribution of trauma care resources. It is a very useful approach to find a reasonable timeline for a particular trauma incident in a region. It can be presented as a heat map and can easily demonstrate the appropriateness of a regional trauma system framework to medical personnel, health and government officials, and policy makers. Mainland China is still in the early stages of trauma center and trauma system development, and the rationale for such a study would be very helpful for trauma system design, especially in providing invaluable information for a region to consider its new trauma system configuration. A similar study was carried out in Shenzhen in 2015, and the outcomes of the study were published in 2017 [14]. These outcomes have been adopted as one of the new Shenzhen trauma system design guidelines.
The World Health Organization and the International Association for Trauma Surgery and Intensive Care’s “Guidelines for trauma quality improvement programs” (WHO, 2009) [26] state that techniques for improving trauma quality include 1) morbidity and mortality (M&M) conferences, 2) preventable death panel reviews, 3) tracking of audit filters, complications, errors, adverse events, and sentinel events, 4) statistical methods: risk-adjusted mortality, 5) corrective strategies and closing the loop, 6) system-wide and pre-hospital quality improvement, 7) role of medical records and trauma registries, 8) appropriateness of using different techniques at different levels of the health care system. Although the concept of trauma auditing and the audit process is new in mainland China, every hospital in mainland China has long adopted a policy based on “discussion of death and difficult cases”. Despite the differences in the process and format of the discussion, the rationale behind it is virtually the same. The trauma audit meeting process usually includes a panel from the hospital trauma committee or regional trauma committee, and reviews specific trauma death cases or any other major trauma cases that could possibly be further improved. The review content usually includes management flow, medical decision making and appropriateness of medical skills. At the end of the meeting, every member of the committee will be required to draw a conclusion as to whether it was an unpreventable death, a potentially preventable death or a preventable death, or whether the management process was appropriate or not, and if not, where the error was/mistakes occurred. Finally, an improvement action protocol and follow-up plan will be developed for further improvement in the future work. Every hospital that takes care of trauma patients should have its own policies and programs for improving the quality of trauma. The purpose of the policy and program should be to continuously identify deficiencies or errors in the trauma care process, and then to develop the action protocol for improvement and an avoidance of recurrence of the same errors.
As mentioned above, the Shenzhen Trauma Surgery Committee has recommended six regional trauma networks. There are a number of reasons behind this. First of all, it is an inclusive trauma system, with six trauma networks covering the entire population of Shenzhen. Shenzhen EMS has 74 network hospitals, including tertiary teaching hospitals, regional general hospitals, community public hospitals and private hospitals. All of these hospitals attend to traumatic incidents and provide primary care to trauma patients. For those hospitals without adequate trauma resources, they either transfer trauma patients from the scene to other major hospitals or, after providing primary trauma care at their own institutions, to other major hospitals if necessary. Secondly, Shenzhen is a city with a population of nearly 20 million and covers an area of 1997.47 square kilometers. Although the air ambulance system was officially established on November 22, 2019, road ambulances are almost the only pre-hospital transfer method for trauma patients [27]. It will be reasonable and feasible for road ambulances to transfer trauma patients to the appropriate hospital within a reasonable timeframe through the six trauma networks' plans. Thirdly, each trauma network will adopt the concept of “1+X”, with “1” indicating the top hospital leading trauma services for that network and “X” indicating the other hospitals within the same network. The criteria for the top hospitals will include both hard and soft criteria. The hard criteria will include trauma surgery and multidisciplinary trauma teams, trauma resuscitation bays, CT in the emergency department, trauma ICUs, trauma wards, department of rehabilitation, and all trauma team members taking care of trauma patients who have received either CTCT® or ATLS® training. The soft criteria will include trauma teaching and research capabilities. A new Shenzhen trauma network program is underway, which will be completed by the Shenzhen Trauma Surgery Committee. This work will be completed and submitted to the Shenzhen Health Commission by June 30, 2021. It is anticipated that the new Shenzhen Trauma System will be fully operational from January 01, 2022.