Care of patients with injuries begins before the patient arrives in the hospital. In NSW the system of care involves ambulance officers and hospital working together to ensure the patient receives the most appropriate care. Historically patients were transported to the nearest hospital. However in order that the patient with serious injuries gets the most appropriate care as soon as possible there was a change in the system of pre-hospital care. This new system empowered the ambulance officers at the scene of injury to make decisions about the transport of patients depending on the patients' injuries and condition. This decision-making process is known as "triage".

   A formal system of pre-hospital trauma triage was introduced by the Ambulance Service of New South Wales in 1992 and monitored by the Trauma System Advisory Committee. The State Trauma Committee developed a plan for implementation of the policy. Part of this plan was to provide specialist trauma services at centralised hospitals within clusters of hospitals. Each Area Health Service has one hospital designated to provide definitive care to critically ill trauma victims. This hospital is known as the Major Trauma Service for the Area.

   So that there is no delay for the patient to receive appropriate care there was a system of "triage" (or transport decision based on the patient's condition and injuries). When a person suffers serious injuries the ambulance officers will take that person to the nearest Major Trauma Service, bypassing the closest hospital if necessary. If the ambulance were to take the patient to a closer hospital but the patient needed the care that he can only get at a Major Trauma Service, then the patient would have to be transferred from one hospital to the other. This delay might be the difference between life and death for the patient.

Major Trauma Services for Heath Service Areas in Metropolitan Sydney

   In metropolitan Sydney the small number of patients identified by ambulance officers as belonging in the seriously ill category (less than10%) are transported directly to the Major Trauma service, bypassing local hospitals if necessary.

   The vast majority of patients continue to be taken to the nearest hospital. A decision to transfer the patient to another hospital may be made after assessment and stabilisation of the patient at the Major Trauma Service. Reasons for transfer might include need for a specialty service that is not available in the Urban hospital e.g. plastic, neurosurgeon or orthopaedic surgeon, or diagnostic (CT scan).

Major Trauma Services for Heath Service Areas outside Metropolitan Sydney

   This system of bypass for seriously injured patients currently only applies in the Sydney metropolitan area. The Illawarra and Hunter Area Health Services are excluded from the pre-hospital triage process at present.

Regional Health Services in Rural Regions in New South Wales

   Trauma is the principle cause of death and disability in children over the age of 1 year in New South Wales. Although many injury prevention programs have had a major impact on deaths and disability, the percentage contribution made by injury to the child death rate is increasing. There are three State Trauma Services for children. These are New Children's Hospital (at Westmead), Sydney Children's Hospital (at Randwick - formerly known as Prince of Wales Children's Hospital), and John Hunter Hospital. The Area Trauma Hospitals for children are Hornsby Hospital, St George Hospital, Nepean Hospital, Royal North Shore Hospital, Liverpool Hospital. These hospitals function as temporary resuscitation stops for seriously injured children. Children for whom definitive treatment cannot be provided will be transferred on to one of the State Trauma Services for Children.

   Ambulance officers triage adult and paediatric patients according to the protocol below, which was developed by key Critical Care Clinicians for the New South Wales Department of Health. Decisions to bypass a local hospital and transport the patient to the Major Trauma service are based on the vital signs of the patient, the presence of serious injuries, or high-risk mechanisms of injury.

• If an ambulance officer considers a seriously ill patient will not survive the time of transport to an Area Trauma Service, the patient should be taken to the nearest hospital en route for urgent resuscitation

• At times the patient has serious injuries but the situation is difficult (entrapment, difficult access, resource limitations, time delay over 30min before delivery to an Area Trauma service, or circumstances which the scene officer determines at his discretion warrant medical assistance). In these instances the scene officer will radio control to notify that "difficult conditions" apply and be advised regarding availability of a primary medical response team.

• If the patient is apparently not seriously injured but has been involved in a mechanism of injury which is high risk, then the officer will re-evaluate the situation and decide whether to take the patient to an Area Trauma Service or to the nearest hospital.

1. NSW Health Department Emergency Services in NSW - Policy for Trauma Service State Health Publication, NSW Health Department 1988 ISBN 0 7305 3317 4

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