Doctors fear 10 years of lifesaving advances are being put at risk by the absorption of the National Trauma Network into Te Whatu Ora. By Donna Chisholm.
When Jevon Puckett began his first shift as on-call consultant surgeon at Hawke’s Bay Hospital on February 21 last year, there were two sorts of cases he fervently hoped he would not have to see. One was a badly injured child. The other was a badly injured liver. “They are terrifying.”
Minutes after ambulance staff brought 19-year-old stonemason Sam Fletcher into the emergency department in Hastings at 8.45am, Puckett realised if there was a god, he wasn’t paying attention that morning.
At 8.08am in Napier, Fletcher’s abdomen had been crushed when he was pinned by six door-sized slabs of stone, each weighing 60-150kg, that had been destined to become kitchen benchtops. The pressure had torn off the top of his liver as effectively as a can opener would take the lid off a tin of beans.
The injury was the equivalent of a scalping to his liver, says Puckett. Fletcher, already pale from internal blood loss and unresponsive because of his plummeting blood pressure, was dying.
Fletcher’s mother, Penny Taylor, driving to the hospital from Napier, says a doctor somewhat ominously called to ask her how far away she was, saying he would have her escorted past the Covid checkpoints into ED “because we don’t have time”.
“All hell was breaking loose. I had no idea what I was walking into. Sam was grey. He looked dead.”
By 9.40am, Puckett himself had wheeled Fletcher to theatre to open his abdomen – “he had a belly full of blood” – and pack the liver to stabilise him and staunch the bleeding.
A decade or so ago, this is where Fletcher’s story – and his life – may have ended. But thanks to the launch of the National Trauma Network in 2012, patients like him are now ferried quickly and efficiently to the major trauma centres best equipped to treat them. Hawke’s Bay Hospital, which does not have specialist liver surgeons able to do the delicate repair required, is not one of them. After emerging from theatre, Puckett was immediately on the phone to the network’s clinical leader, storied surgeon Professor Ian Civil. By 5pm, Fletcher, accompanied by two doctors and a nurse, was on a plane bound for Auckland City Hospital.
Keeping him at Hawke’s Bay, Civil knew, was a likely death sentence. “I said, ‘Look, you’ve got one chance, the longer you keep him there, the more likely he will circle the drainpipe and end up going down.’”
Before the network, he says, everyone was treated in the closest hospital and only in exceptional circumstances – “virtually never” – were patients shifted to another hospital. “But getting patients to the hospital that can treat all their injuries has long been associated with better outcomes.”
Fletcher was one of those “better outcomes”. Today, after 13 surgeries, two months in hospital and more than a year recovering on ACC, he is back at work – at a new job as a stonemason in Perth, working, he says, on much smaller slabs of stone – and reflecting on how close he came to dying.
“It’s a cliché to say they saved my life, but they did. It’s made me realise life is a bit more precious than I was treating it.”
But now Civil fears that years of progress in trauma care may come to a halt with the transfer of the network, on July 1, from the control of the Accident Compensation Corporation to Te Whatu Ora, the body that last year took over from the country’s scrapped district health boards. He and the network’s national programme director, Siobhan Isles, a former trauma nurse who’s managed the network since 2014, were previously contracted by ACC to run it, allowing nimble decision-making and the autonomy to introduce research-led initiatives.
Isles’ contract wasn’t renewed because she was not previously employed by Te Whatu Ora and new roles are going to existing staff. Civil, a former president of the Royal Australasian College of Surgeons who was made a Companion of the NZ Order of Merit in 2016 for services to health, says she has played a vital role in its success. He has signed a six-month contract to oversee the transition. “I was very tempted to just walk away from it in frustration, but I felt I’d be abandoning colleagues who had put a lot into the programme if I did that. We’ve been largely unfettered by bureaucracy for the past eight years.”
The problem with the transition, he and Isles say, are the layers and layers of just that within Te Whatu Ora – and what Isles calls its desire to “reinvent the wheel”. Civil also feels the transition, which should have taken a year or two, was rushed to meet the arbitrary July 1 deadline for political ends.
“I think it’s probably driven by the government wanting to [make it] seem that their healthcare policy has produced improvements prior to the current election.”
He describes the loss of Isles, who previously worked for Médecins Sans Frontières and the Royal London Hospital’s Helicopter emergency medical service, as a “beheading”.
Isles is frustrated that Te Whatu Ora seems to be trying to fix something that isn’t broken. “We’ve got a simple, high-performing team, we know what we’re doing and suddenly we’re told we have to completely change the structure and break everything into little bites and put one bit in this place and another in another place,” she says.
“It’s led by people who have limited experience in clinical networks, and it’s magically supposed to work out just fine?”
She says the network had wanted to do a staged handover, but the July 1 deadline had made this impossible.
Te Whatu Ora talks about wanting to improve outcomes for Māori patients when that’s been a key focus – and result – of the network to date, she says. Before it, Māori patients with traumatic brain injury were less likely to be transferred to a neuroscience centre such as Auckland, Waikato, Wellington or Christchurch, but that is largely corrected now.
“We’ve learnt an enormous amount in terms of improving outcomes for Māori, who have a higher burden of injury than non-Māori, and we have improved the number of Māori who survive,” says Isles. “We’ve also done a lot of work on how to improve the experience for Māori once they get into hospital, and particularly in the transition of care to rehab and their experiences in rehab, so it feels like Groundhog Day.
“The key thing is experience in clinical and network leadership – you can’t read a book about how to do it.”
Silos or limbo
In June, surgeons Chris Wakeman of Christchurch and Matthew Hope of Queensland, co-chairs of the Royal Australasian College of Surgeons bi-national trauma committee, wrote to Health Minister Ayesha Verrall to raise their concerns about the transition. “The proposal that the structure, executive leadership, functions and relationships are summarily cancelled on July 1 to be dismembered into several different silos within Te Whatu Ora or ACC or simply sent into limbo without any meaningful discussion with the members of the network is a huge risk.” They said resolving inter-regional inequalities in trauma services should be a key goal for Te Whatu Ora, but would be very difficult to achieve without the network’s institutional knowledge.
Dr Pete Watson, Te Whatu Ora’s national director, medical, and Dr John Robson, chief clinical officer and head of health partnerships with ACC, responded to a list of questions about the transition, saying the agency facilitated a “more cohesive approach” and would best support continuing improvement in trauma outcomes. They say the network will be located in the hospital and specialist services group and linked to regional trauma networks to ensure initiatives are effectively evaluated and delivered. ACC has committed to funding the network’s activities for a further two years.
“A transition plan has been jointly developed with ACC to ensure there are no gaps in continuity on the work of this programme and the same level of funding will be provided.”
The response says the “principle” of transition has the support of the network’s governance group.
Civil and Isles agree that the transition isn’t necessarily a bad thing per se, but, says Civil, the structure being put in place is “dysfunctional”.
“It’s not the same structure; there are so many different moving parts. You meet with someone who says, ‘Well, that sounds like a good idea, but, of course, I can’t make the decision, it’s higher up.’ And you go higher up and you find it’s not that person, either, it’s someone higher up again, and you end up forever not making a decision.”
Fine margins
Ironically, in a remarkably prescient editorial in the New Zealand Medical Journal in 2017, Civil and Isles called for the trauma network structure to be “locked in”.
“The greatest threat to achieving high-quality trauma care in New Zealand at this point is governance stability rather than clinical variability. The difference in outcomes between optimal and suboptimal care can impact on survival, total cost of care and quality of life in the months and years that follow.”
One of the network’s key advances has been the development of a detailed trauma registry that collects information on patient treatment and outcomes, which has identified and helped to address gaps. “Trying to do quality improvement without a database is like trying to play darts without a dartboard,” says Civil. But under Te Whatu Ora, although that will still exist, it will be run by the health authority’s data and digital team.
He fears further improvements to the network are at risk. One of his top priorities is to introduce a single point-of-contact number for clinicians in regional centres to call when they have a major trauma patient who needs to be transported to a city hospital. Hospitals in Northland and Auckland already have an 0800 number to call that connects to an intensive-care specialist at Auckland City Hospital who can advise on the patient’s care and expedite the transfer. “One of my unfinished pieces of business is to have a single point-of-contact number for all our tertiary hospitals, including Christchurch and Wellington.”
![Professor Ian Civil says "we’ve been largely unfettered by bureaucracy [under ACC] for the past eight years.” Photo / Supplied](https://www.nzherald.co.nz/resizer/v2/4II3SDKHGFF6THMXX77ZFCNLJA.jpg?auth=e5575c64f6ee80bc071c0cc027a014bd893d4d7c7e026db727e376999bd626bd&width=16&height=12&quality=70&smart=true)
Civil and Isles say the 0800 number for regional clinicians is an invaluable tool for cutting through the red tape that used to surround hospital transfers and still frustrates doctors in other areas. Isles says things changed in the north after the experience of a doctor in Kaitaia in 2013. “She was there on her own and had a major trauma patient and had to make 27 phone calls in and out to Auckland to try to get this patient transferred.”
Civil says the network has been trying to benchmark its results against its Australian counterparts, where 72% of patients are currently taken initially to the hospital that’s best equipped to treat them. He says New Zealand is getting up to 81%.
The network fosters a “no refusals” policy at receiving hospitals, but Civil concedes that in some areas, this isn’t working in practice as well as it could. He has heard from some doctors at regional hospitals still facing frustrating delays, which is why he wants to introduce the single point of contact for all regions.
“It’s ultimately still driven by the clinicians and their behaviour, and there are still examples where we have work to do.” Doctors in one region told him they were slow to refer patients to the closest main hospital because “the neurosurgeons never seem to want to take the cases and you can get five different answers, depending which neurosurgeon is on. They say it’s not the sort of system they would like and they are absolutely right.”
He says referring hospitals are also sometimes told there are “no beds” or “we are too busy”. “But if that same patient came in to the ED of their own hospital, there wouldn’t be any question of beds because the patient would be there and they would find a bed.”
Vital signs
The national network can point to substantial gains in serious-injury outcomes and management over 10 years.
A data registry the National Trauma Network has developed over the past decade has been key to its operation and its success, says clinical director Ian Civil. “It shows your current position and what the deficit is.”
It’s widely known internationally, for example, that for patients with a head injury, the time to treatment, particularly if it’s surgical treatment, is crucial to the outcome. But doctors won’t know what treatment is required without a CT scan. Scans should be done within two hours of the injury and surgery within four hours.
“It’s not like 3 hours, 59 is great and 4 hours, 1 minute not great, but, for example, the database told us there were quite a few places where CT scans weren’t happening for three or four hours after injury.”
The information allowed the network to launch a quality improvement programme to reduce that, with the registry confirming whether those targets are met.
Destination policies for ambulance staff have also changed, ensuring that patients get to the best hospital for their care, rather than the closest.
“The road-to-zero target is that every single person goes to the hospital that’s capable of managing all their injuries and no one ever has to be transferred between hospitals,” says Civil. “That’s theoretical, because you can’t possibly know all the injuries that a patient might have at the scene.” Of course, this also has disadvantages, with the risk that tertiary hospitals become overwhelmed.
The network has also built strong relationships with Waka Kotahi NZ Transport Agency and Te Tāhū Hauora, the Health Quality & Safety Commission and introduced simulation-based training to help emergency department staff work more effectively together.
The ACC’s $1.5 million annual funding also allowed the network to contract researchers at the University of Otago to follow up a cohort of trauma patients injured in the 12 months to July 2021. That data is not yet ready for publication, Civil says.
“We can tell from hospital data whether people live or die and how long they spend in hospital, but what we can’t tell is what they are like months or years after their injury, which is really the most important thing for the vast number of patients who survive.
“If you have a bad injury, you want to know you are going to survive with as good a quality of life as you can possibly have.”
Other key achievements in the past decade include:
- A reduction in overall case death rates from 12% to 7.4%.
- The standardised death rate for Māori patients with major trauma has fallen 25% since 2015, compared with 10% for non-Māori.
- The average cost of major ACC trauma claims has reduced by $7000 over the past two years, to $45,000.
- The number of patients getting CT scans at the optimal time has increased from 52% to 65%.
- Deaths from critical haemorrhage have fallen from 12% to 3%.
Left in awe
The system helped save the life of Rotorua woman Marg Maniapoto, who was critically injured in a fatal head-on crash just north of Whangārei on New Year’s Day, 2021. Although she escaped the wreckage of the family’s written-off car – carrying her, her husband, Maru, and daughter, Tiaria, to a holiday in Kerikeri – with what she thought were only minor injuries, she had, in fact, suffered potentially lethal crush damage from her seatbelt.
“I hit the windscreen, but didn’t lose consciousness,” she says. “I thought, ‘I’ve hurt my back and I’m a bit sore across the midriff but I’m not too bad.’” But within hours, she was on an emergency flight to Auckland after doctors realised she had injured not only her bowel, but more crucially, the body’s main blood vessel, the aorta. This meant vascular surgery might be needed that the surgeons in Northland were not trained to perform.
While her husband and daughter had only minor injuries, Maniapoto was admitted to the intensive-care unit, required three operations and spent two months in hospital before being discharged with a colostomy bag which she had for a year. Although she did not need a repair to her aorta, the injury required ongoing six-monthly checks.
Maniapoto, who manages a private training establishment for a Māori community health provider, has been left in awe by the quality of the care she received, medically, surgically and culturally. “The team, the staff, the speed at which they reacted and the incredible skill from Auckland City Hospital saved my life, and my whole family says that. I realised how lucky I was that that team, that network and that service were in place for me, because it could have been such a different story.”
Like Sam Fletcher, the ordeal has had an existential impact on her life. “Every day, I am always saying let’s make the most of it. I know I’m a little more appreciative of life and opportunities and time and how precious that is.” At 57, Maniapoto completed her first 10km walk in 10 years in this year’s Rotorua Marathon in May in the respectable time of 1hr 36m 45s, and she found she hadn’t lost her competitive edge.
“The time was better than I thought. I did a little bit of running at the end to pass a lady I worked with.”
In survival stories such as Maniapoto’s and Fletcher’s, “if” is a word that crops up time and again: “If”, the doctors said, Fletcher had been a few years older; “if” the injury had opened that crucial blood vessel the interior vena cava instead of coming within a couple of millimetres of it; “if” neither of them had got to the best possible specialist care in time, they might not have lived.
Civil knows he and his team can’t control all those variables, but they’re determined to remove the last one from that life-or-death equation.