This month’s edition of the NZMJ has two articles on trauma care in New Zealand.
There have now been two annual reports from the New Zealand Major Trauma Registry (NZ-MTR). The second report covering 2016 to 2017 was a more comprehensive review with most regions now having data inputted into this review. The NZ-MTR enables New Zealand to have a national view of trauma treatment and outcomes for the first time. The aim of the NZ-MTR is to “inform quality improvement and injury prevention initiatives and potentially decrease the burden of injury on all New Zealanders”.1
With the collection of data, we now have more research coming out of the centres, giving us a better idea of where we are in the epidemiology and treatment of trauma. One limitation of trauma registry data is that it only contains information on admitted patients, with injuries treated in the emergency departments who are discharged or who are to be followed up in the outpatients and those in the community not included. True incidence and prevalence are not calculated, meaning that it is representative but lacks a true denominator. Another problem with collecting data for the Major Trauma National Clinical Network and extrapolating it out means the non-major data with an injury severity scale less than 12 are not necessarily included again, affecting the denominator.
The first article from the Midlands region reminds us that we are a rural county and while road traffic crashes make up the majority of the causes of trauma in New Zealand, a significant burden of diseases does come from working with livestock. This review of their data gathered over 2012 to 2015 from the Midlands area showed that there is a substantial burden of trauma caused by livestock in the Midlands region. In 2018 it has been reported by the media that Waikato has the most substantial amount of dairy farms in New Zealand with just over 4,200 dairy farms. Working with Cattle caused over 72% of the injuries identified in this review. This has implications for WorkSafe NZ, and some of their key recommendations are around cattle farming, particularly around the calving period and sheep farming around the time of shearing and crutching.2
Midlands have been able to utilise data from their database, which includes patients with a variety of injuries and of varying severity. Not all regions can capture all data—in Christchurch for example, only the major trauma data (ISS<12) is captured even though it services remote and farming type areas they had under five presentations from livestock in the last two years resulting in major trauma. Most injuries in Canterbury seen with animals were horse-related injuries, which represent an estimated 4.4% of all our major trauma.
The second article comes from Christchurch and looks at the use of tranexamic acid (TXA) in major trauma admitted to Christchurch hospital. The use of TXA since the publications of the Crash 2 study has become the standard of care in many countries. This trial showed that the early administration of TXA to trauma patients reduced significant bleeding and death from haemorrhage. All-cause mortality was significantly reduced with TXA. However, there is a concern around this publication that it was conducted in 274 hospitals in over 40 countries, and results from these patients do not necessarily pertain to patients in our hospital. The article by Nicholas Chapman shows TXA was found to be under-utilised and significant departures from best practice were found. There was also a delay beyond the three-hour therapeutic window occurring in a quarter of patients, increasing the risk of mortality secondary to haemorrhage.3
This article has not identified the difference in time from the TXA being given in relation to when the Massive Transfusion Protocol (MTP) was started. It would be interesting to know if the MTP activation resulted in TXA being given or whether it was decided on later. TXA is not included in the MTP boxes that are sent to the emergency department.
With only 19% of second doses given it would be interesting to know if the dose was not given as the patient was responding to blood products or if the patient was moved for more definitive care. Not all areas in Christchurch Hospital hold TXA as ward stock. Was the delay in relation to other injuries?
This data is of concern that we are not following the modern treatment of trauma patients. Hopefully, education around the use of TXA can lead to its better use. What are other elements of modern trauma care likewise not being introduced and done correctly?
At the end of last year, the Royal Australasian College of Surgeons (RACS) Trauma Verification team conducted a review of the system of trauma care in New Zealand. The task was to perform an analysis of the New Zealand system level rather than at any particular DHB. One of their findings was a perceived risk to the delivery of quality care throughout New Zealand. Many improvements have been made in the last 5 to 10 years in trauma care in New Zealand, but there is still much work to be done to introduce a complete system throughout the country. Data collected by the regions can lead to better quality control and also identify areas of concerns or need which are unique to New Zealand. Last year in this Journal, Professor Civil questioned “Is high-quality trauma care ‘business as usual’ in New Zealand?” He and fellow author Siobhan Isles suggested that “New Zealand is on the cusp of establishing a world-class trauma system. Many of the building blocks are in place with national and regional guidelines in both the pre-hospital and hospital phases of care established.”4 A year on and following the RACS trauma review, the government and the DHBs need to make a substantial investment to bring together those building blocks to give us a world-class system.