Original article

A major trauma centre is a specialty hospital not a hospital

of specialties
R. A. Davenport1 , N. Tai2 , A. West2 , O. Bouamra3 , C. Aylwin2 , M. Woodford3 , A. McGinley2 ,
F. Lecky3 , M. S. Walsh2 and K. Brohi1
Trauma Clinical Academic Unit, 1 Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Royal London Hospital,
and 2 Barts and the London NHS Trust, London, and 3 Trauma Audit and Research Network, University of Manchester, Department of Emergency
Medicine, Hope Hospital, Salford, UK
Correspondence to: Professor K. Brohi, Trauma Clinical Academic Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University
of London, Second Floor Front Block, Royal London Hospital, Whitechapel, London E1 1BB, UK (e-mail: karim@trauma.org)

Background: High estimates of preventable death rates have renewed the impetus for national

regionalization of trauma care. Institution of a specialist multidisciplinary trauma service and performance
improvement programme was hypothesized to have resulted in improved outcomes for severely injured
patients.
Methods: This was a comparative analysis of data from the Royal London Hospital (RLH) trauma registry
and Trauma Audit and Research Network (England and Wales), 20002005. Preventable mortality was
evaluated by prospective analysis of the RLH performance improvement programme.
Results: Mortality from critical injury at the RLH was 48 per cent lower in 2005 than 2000 (179
versus 342 per cent; P = 0001). Overall mortality rates were unchanged for acute hospitals (43 versus
44 per cent) and other multispecialty hospitals (87 versus 73 per cent). Secondary transfer mortality
in critically injured patients was 53 per cent lower in the regional network than the national average
(52 versus 110 per cent; P = 0001). Preventable death rates fell from 9 to 2 per cent (P = 0040) and
significant gains were made in critical care and ward bed utilization.
Conclusion: Institution of a specialist trauma service and performance improvement programme was
associated with significant improvements in outcomes that exceeded national variations.
Paper accepted 20 July 2009
Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.6806

Introduction

Trauma is a leading cause of death in the UK, accounting

for over 16 000 deaths per year1 . Severely injured patients
have a 20 per cent higher in-hospital mortality rate in
England and Wales2 than in the USA3 , and there has
been a plateau in trauma outcomes since 19944 . A
recent independent national review of the management
of severely injured patients reported that 52 per cent of
trauma patients receive substandard care5 , and there may
be upwards of 3000 preventable trauma deaths in England
and Wales every year6 .
There is now a large body of evidence demonstrating that
organization of trauma care into regional systems improves
The Editors are satised that all authors have contributed signicantly
to this publication

Copyright 2010 British Journal of Surgery Society Ltd

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outcomes7 10 and signicantly reduces preventable death

rates within a few years of institution11 13 . Following the
publication of the Healthcare for London: A Framework for
Action report in 200714 , and studies demonstrating the
need for a national trauma system15 19 , it seems likely
that regionalization of trauma care will become a reality
in England and Wales within the next few years. Success
in improving trauma outcomes will be dependent on the
optimal design, organization and operation of these systems
and their components.
Within a regional system, specialist major trauma
centres network with prehospital care providers and acute
hospitals (AH) to deliver optimum care in the most
appropriate facility at the most appropriate time20,21 . A
trauma centre is commonly thought of simply as a large
hospital with all relevant specialties and facilities on site.
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R. A. Davenport, N. Tai, A. West, O. Bouamra, C. Aylwin, M. Woodford et al.

The institution at the centre of the present study is a

large urban multispecialty academic hospital with dedicated
trauma resources. Designated as a pilot trauma centre
in 1988, an external review in 1995 demonstrated little
observable impact on outcomes22 . A later internal audit
again demonstrated minimal improvement in survival and
multiple variances from the standard of care.
In response, a number of major changes were made to the
delivery of trauma care and to the supporting management,
clinical governance and educational frameworks. A
multidisciplinary trauma service was formed in 2003 with
overall responsibility for all trauma patients. A dedicated
trauma ward was opened in 2005. A formal performance
improvement programme was instituted to review the
process of care for all deaths and serious morbidities,
and to quality assure the development and implementation
of management guidelines. Local AH were given a single
access point for contact for secondary transfers, a policy of
automatic acceptance was adopted and the ethos for duty
of care was transferred to the receiving trauma centre.
The aim of this investigation was to assess the impact
of these changes on the outcomes and process of trauma
care. The introduction of integrated governed care was
hypothesized to have led to a reduction in the mortality
rate for severely injured patients and a reduction in the
preventable death rate. These changes were proposed
not simply to be a reection of national improvements
and would not be expected to be observed in other
multispecialty hospitals (MSH). It was also hypothesized
that improvements in access to the trauma network had
resulted in a reduction in mortality rate for patients
requiring secondary transfer. Finally, the impact on length
of stay and critical care utilization, and on the process
of care as measured by time to critical interventions, was
examined.

Methods

An observational multimodal study was performed using

the database from the Trauma Audit and Research
Network (TARN) for England and Wales2 , the Royal
London Hospital (RLH) trauma registry and the US
National Trauma Databank (NTDB)3 . The efcacy of the
performance improvement programme at the RLH was
evaluated by analysis of preventable deaths from trauma.
Some 106 (480 per cent) of 221 receiving hospitals for
trauma in England and Wales submitted retrospective data
to the TARN (20002005). Data for 20062007 were
incomplete and therefore unavailable for comprehensive
analysis. Patients excluded from the data set were those
Copyright 2010 British Journal of Surgery Society Ltd
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discharged within 3 days, and those with fragility fractures

or single uncomplicated limb injuries.
TARN data were separated into three groups: those
from the RLH, those from 13 MSH (institutions with full
surgical capability and specialty surgical services including
at least a neurosurgery service, but excluding the RLH) and
other AH without specialist services such as neurosurgery.
The NTDB collates comprehensive trauma patient data
yearly from approximately two-thirds of trauma centres
in the USA and produces annual reports of a rolling
data set covering the previous 5 years. The 20022006
NTDB data set was available for analysis. The RLH
registry contains prospectively collected data on all injured
patients who meet the criteria for trauma team activation
in the emergency department, with follow-up until death
or discharge. Undertriaged patients are those who meet
trauma activation criteria but do not receive a trauma team
response. After admission and identication of signicant
injury, these patients are routinely referred to the trauma
service and therefore included in the RLH registry.
Survival outcome, assessed at discharge or 30 days after
admission to hospital, was evaluated from the TARN
data set to investigate overall mortality. Outcome analysis
was stratied by shock (systolic blood pressure (SBP) on
admission less than 100 mmHg), major head injury (score 3
or more on the Abbreviated Injury Scale) and standardized
Injury Severity Score (ISS)23 categories: severely injured
(ISS over 15) and critically injured (ISS more than 24).
Comparative analysis was performed between patients
transferred to either the RLH or other MSH, from local
referring AH.
For the preventability analysis, 3 years of trauma deaths
at the RLH were prospectively analysed to identify
avoidable errors. All trauma patients who died either
in the emergency department or during admission were
included. The American College of Surgeons (ACS)
performance improvement model24 was incorporated
into the RLH multidisciplinary peer review process to
enable classication by consensus of each death as nonpreventable, possibly preventable, probably preventable or
preventable. Although a subjective process, this has been
shown to produce robust and consistent analysis of clinical
and system failures25 28 , and a standardized process in
trauma care.
Data on length of stay and critical care use were extracted
from the RLH registry to evaluate the effect of the trauma
service on quality of care over time. Hospital admission
statistics on the rst 1000 patients admitted to the trauma
service were compared with those of a subsequent cohort of
1000 sequential patients admitted immediately following
the opening of the dedicated trauma ward. The TARN
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Multidisciplinary trauma services

40

111

England and Wales

RLH
USA

ISS > 24
50

35
Mortality (%)

30
Mortality (%)

ISS > 15

60

25
20
15

40
30
20

10
10
5
0

ISS > 15

ISS > 24

Mortality in 2005

2000

2001

2002

2003

2004

2005

Annual mortality at RLH

Comparative survival (Ws)

18
15

9
6
3
0
3
6
9
2000

Mortality following severe injury. a Mortality in 2005 in

the USA, England and Wales and the Royal London Hospital
(RLH) for severely injured (Injury Severity Score (ISS) more
than 15) and critically injured (ISS over 24) patients. *P = 0005
(2 test). b Annual mortality at the RLH for injured patients,
20002005. Signicant reductions in mortality from baseline
(2000) were apparent from 2003 onwards for both severely and
critically injured patients (P < 0001 and P = 0001
respectively; 2 test for trend). c Comparative survival (Ws
statistic), 20002005, shown as the annual number of
unexpected survivors per 100 severely injured patients at the
RLH. Error bars represent 95 per cent condence intervals

Fig. 1

12

2001

2002

2003

2004

2005

Comparative survival at RLH

data set was scrutinized for process of care markers

to compare internal organizational aspects of trauma
care between hospital groups. Times from admission to
key intervention or investigation were compared against
national agreed standards of care, as dened by time
to computed tomography (CT) less than 4 h, time to
laparotomy below 2 h, time to laparotomy in shocked
patients within 1 h and time to craniotomy less than
4 h.

Statistical analysis
2 test and Fishers exact test were used for analysis of categorical data. Students t test and MannWhitney U test
were used for normally and non-normally distributed interval data respectively. The Ws statistic was used to compare
year-on-year outcomes at the RLH with the national outcomes from the England and Wales data set29 . Ws is a
directly standardized summary statistic that represents the
weighted average of the excess number of survivors per 100
cases for each institution. The weights are represented by
the proportion of cases from a standard population (England and Wales) within each probability of survival band
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(Ps model30 ). For comparison of Ws statistics, pairwise

comparisons by means of t tests with Bonferroni correction were used. P < 0050 was considered to indicate
signicance.

Results

In 2005, mortality from severe injury (ISS over 15) was

20 per cent higher in England and Wales than in the
USA (TARN 206 per cent versus NTDB 172 per cent;
P = 0005) (Fig. 1a). At the RLH, mortality rates from
severe injury fell by 48 per cent from 2000 to 2005
(342 to 179 per cent; P = 0001) (Table 1), with a sharp
decrease in mortality rate associated with institution of the
multidisciplinary trauma service in 2003 (Fig. 1b). There
was no signicant improvement in standardized survival
associated with trauma care at the RLH until 2003. By
2005, survival at the RLH was better than the national
average, and was equivalent to that in the USA (Fig. 1a),
despite patients at the RLH being more severely injured,
and more likely to be in shock and to have sustained a
penetrating or severe traumatic brain injury (Table 1). The
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R. A. Davenport, N. Tai, A. West, O. Bouamra, C. Aylwin, M. Woodford et al.

Table 1 Demographics, injury characteristics and mortality rates among trauma patients admitted directly or transferred to a secondary
care hospital
Royal London Hospital

No. of hospitals
No. of patients
Men
Age (years)*
ISS*
> 15
> 24
SBP < 100 mmHg
Penetrating injury
Head AIS 3
Deaths
ISS > 15
ISS > 24

England and
Wales 20002005

USA
20022006

Acute hospitals
20002005

Multispecialty
hospitals 20002005

20002005

2000

2005

106
75 325
43 529 (578)
48 (3167)
9 (910)
11 765 (156)
6047 (80)
3317 (44)
1980 (26)
7587 (101)
3996 (53)
2974 (253)
2413 (399)

712
1 485 098
966 975 (651)
44 (2665)
9 (410)
332 780 (224)
142 133 (96)
106 926 (72)
151 377 (102
121 860 (82)
65 897 (44)
51 766 (157)
41 623 (293)

92
55 729
30 699 (551)
51 (3369)
9 (99)
5776 (104)
2607 (47)
2345 (42)
1257 (23)
3285 (59)
2360 (42)
1572 (272)
1210 (464)

13
17 113
10 959 (640)
44 (2862)
9 (917)
5025 (294)
2803 (164)
806 (47)
470 (27)
3609 (211)
1371 (80)
1145 (228)
970 (346)

1
2483
1871 (754)
36 (2652)
10 (925)
964 (388)
637 (257)
166 (67)
253 (102)
693 (279)
265 (107)
257 (267)
233 (366)

1
484
359 (742)
37 (2855)
9 (920)
161 (333)
99 (205)
24 (50)
30 (62)
123 (254)
56 (116)
55 (342)
47 (475)

1
380
289 (761)
35 (2452)
13 (925)
173 (455)
118 (311)
36 (95)
68 (179)
119 (313)
32 (84)
31 (179)
30 (254)

Values in parentheses are percentages unless indicated otherwise; *values are median (interquartile range). Trauma Audit and Research Network
(TARN): England and Wales, acute hospitals, multispecialty hospitals and the Royal London Hospital. US data were obtained from the National Trauma
Databank. ISS, Injury Severity Score; SBP, systolic blood pressure; AIS Abbreviated Injury Scale score. P < 0050 versus TARN, P < 0050 versus
multispecialty hospitals, P < 0050 versus acute hospitals, P < 0050 versus Royal London Hospital 2000 (2 test, except MannWhitney U test for ISS
and age).

Ws model estimated that, by 2005, management at the

RLH resulted in 34 additional survivors per 100 trauma
patients compared with the national average, rising to
11 additional survivors per 100 for the severely injured
subgroup (Fig. 1c). This equated to approximately 55 extra
survivors per year at the RLH based on the current rate of
trauma admissions.
This improvement in additional survivors was not a
reection of national changes in the delivery of trauma
care across England and Wales. Overall mortality rates
from 2000 to 2005 were unchanged for non-specialty AH
(43 versus 44 per cent) and MSH (87 versus 73 per cent).
There was a signicant reduction in mortality rate for
severely injured patients between 2000 and 2005 (TARN
data: 291 versus 206 per cent; P < 0001) but outcome was
always worse if severely injured patients were admitted to
non-specialty AH (2005 mortality rates: AH 252 per cent
versus MSH 169 per cent; P < 0001). Improvements in
survival of severely injured patients at the RLH signicantly
outpaced any changes at MSH (improvement of 13 versus
nine additional survivors per 100 patients; P < 0001)
(Fig. 2a).
Severely injured patients arriving in shock (SBP below
100 mmHg) showed minimal benet from treatment at
MSH (2005 mortality rates: AH 371 per cent versus
MSH 321 per cent). A signicant improvement in this
patient group was evident only at the RLH. The 2005
mortality rates for severely injured patients in shock
at the RLH were 65 per cent less than at MSH (111

versus 321 per cent; P = 0034) (Fig. 2b). Mortality rates

associated with traumatic brain injury (head AIS 3 or more)
decreased at the RLH and at MSH (from 283 per cent in
2000 to 177 per cent in 2005 at MSH; P < 0001). There
was no improvement in outcomes from traumatic brain
injury at AH and by 2005 the mortality rate was 83 per cent
worse than for MSH (324 versus 177 per cent; P < 0001).
The effect of local hospital network arrangements on
the mortality rate among patients transferred to the
RLH was examined. Demographics, injury characteristics
and admission physiology were similar between patients
transferred to the RLH or MSH, but the former patients
were more likely to have sustained penetrating injury (144
versus 28 per cent; P < 0001). The severity of traumatic
brain injury was similar in the two groups. Direct local
hospital emergency department referral to the RLH trauma
service was associated with a signicantly lower mortality
rate than transfer arrangements to other MSH (Fig. 2c).
The effect was maximal in the critically injured patients,
with a 53% lower mortality in our regional network than
the national average (52 versus 110%; P = 0001).
To substantiate these improvements in survival, analysis
of other measures of quality and process of care was
performed. In 2004, ve deaths (9 per cent) were judged to
have been preventable by consensus peer review, compared
with a single death in both 2005 and 2006 (2 and
1 per cent respectively), a statistically signicant reduction
(P = 0023) (Table 2). In 2004, preventable deaths were
the result of delay to haemorrhage control (ve patients)

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Multidisciplinary trauma services

113

14
Change in comparative
survival (Ws)

12
10
8
6
4
2
0

RLH

AH

RLH
MSH
AH

70
60
Mortality (%)

MSH

Comparative survival

50
40
30
20
10
0

ISS > 15

30

Table 2 Trauma admissions to the Royal London Hospital

20042006

RLH
MSH

25
Mortality (%)

ISS > 24

Mortality in 2005, patients in shock

20
15
10
5
0

ISS > 15

and delay to craniotomy for evacuation of intracranial

haemorrhage (one). Both deaths in 20052006 were
classied as preventable, due to delays before arrival at
the RLH. During this period the undertriage rate (patients
admitted and meeting trauma team activation criteria who
did not receive a trauma call) increased from 07 to
38 per cent (Table 2). These patients were not at increased
risk of death.
The impact of a dedicated trauma ward on inpatient
stay was assessed by examination of bed-day utilization of
1000 patients before and after its opening. Demographics
and injury characteristics were similar for both patient
cohorts, although those treated before the opening of the
ward were more likely to be shocked and to have sustained
penetrating injury than the subsequent 1000 patients. In
spite of this, hospital stay decreased signicantly in severely
injured patients (20 versus 13 days; P < 0001) and in the
critically injured (25 versus 14 days; P < 0001). Similar
reductions were seen in critical care bed occupancy with a
decrease of 1 day (3 versus 2 days; P = 0002) and 2 days (5
versus 3 days; P = 0032) in severely and critically injured
patients respectively.
Median time from admission to CT was signicantly
reduced at the RLH (77 min) compared with both MSH
and AH (97 and 91 min respectively). Although the
difference in medians was small, delays of more than
4 h occurred in only 15 per cent of patients at the RLH

ISS > 24

Mortality in 20002005, transferred patients

Comparative outcomes at the Royal London Hospital

(RLH), multispecialty hospitals (MSH) and acute hospitals (AH).
a Change in comparative survival (Ws statistic) from 2000 to
2005 for severely injured patients (Injury Severity Score more
than 15). *P < 0001 (multiple t test comparisons with
Bonferroni correction). b Mortality rates in 2005 for severely
and critically injured patients in shock. *P = 0034, P = 0010,
P = 0092, P = 0162 (2 test). c Mortality rates in 20002005
for patients transferred to specialist centres. *P = 0023,
P = 0014 (2 test). Error bars represent 95 per cent condence
intervals
Fig. 2

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Trauma team activations

Total admissions
Undertriaged patients
Deaths
Men
Age (years)*
ISS*
> 15
> 24
SBP < 100 mmHg
Penetrating injury
Head AIS 3
Transfer out in < 30 days
Transfer out ISS*
Deaths
Preventable
Probably preventable
Possibly preventable
Not preventable

2004

2005

2006

688
582
4 (06)
1 (25)
478 (821)
33 (2347)
9 (419)
188 (323)
112 (192)
39 (67)
119 (204)
148 (254)
38 (65)
18 (926)
55
5 (9)
1 (2)
8 (15)
41 (75)

846
671
17 (20)
1 (6)
546 (814)
32 (2344)
9 (217)
215 (320)
122 (182)
69 (103)
146 (218)
170 (253)
48 (72)
17 (1325)
56
1 (2)
1 (2)
15 (27)
39 (70)

1067
811
41 (38)
0 (0)
682 (841)
32 (2245)
9 (418)
275 (339)
155 (191)
80 (99)
213 (263)
200 (247)
45 (55)
16 (820)
80
1 (1)
1 (1)
11 (14)
67 (84)

Values in parentheses are percentages unless indicated otherwise; *values

are median (interquartile range). ISS, Injury Severity Score; SBP, systolic
blood pressure; AIS Abbreviated Injury Scale score. P < 0050 (2 test
for trend); P < 0050 versus 2004 (2 test).

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R. A. Davenport, N. Tai, A. West, O. Bouamra, C. Aylwin, M. Woodford et al.

compared with 128 per cent in AH and 138 per cent

in MSH (P < 0001). Over the interval 20002005 the
number of patients waiting more than 4 h for CT at
the RLH fell from 42 to 15 per cent, despite the large
increase in patient load. In contrast, delays increased
at MSH, with 118 per cent of patients waiting more
than 4 h for CT in 2005 compared with 64 per cent in
2000 (P = 0012). Signicantly more patients at the RLH
underwent laparotomy within the nationally agreed best
practice time frames, in particular for patients arriving
in shock. Overall, at the RLH 60 per cent of patients
in shock received a laparotomy within 1 h of arrival in
2005 compared with 50 per cent in 2000. Conversely, at
MSH only 9 per cent of patients underwent laparotomy
within 1 h in 2005, down from 33 per cent in 2000. Time
to emergency craniotomy was a median of 90 min faster
at the RLH than at other MSH, with a non-signicant
increase in the number of patients undergoing craniotomy
within 4 h (41 per cent in 2000 versus 58 per cent in 2005;
P = 0069).
Discussion

This study has shown that institution of a specialist trauma

service and adoption of a robust clinical governance
programme can achieve signicant improvements in the
process of care and outcomes from severe injury. These
improvements were in excess of any national improvements
in trauma care over this time period. Improvements in the
process and quality of care delivered signicant reductions
in critical care and hospital stay.
There is a large body of literature demonstrating
that regional population-based trauma systems improve
outcomes from severe injury from the USA10,31,32 and,
more recently, Australia33 . Less clear is how major trauma
centres within these systems should optimize the delivery
of care. The concept of trauma care centred on a dedicated
surgical-led service combined with a robust performance
improvement programme is the central theme of the ACS
trauma centre designation and verication programme21 .
Few studies, however, have demonstrated the benet of
this system over and above the simple presence of all
trauma-related surgical specialties. A recent national study
in the USA suggested that survival was up to 30 per cent
better when critically injured patients were treated in
an ACS designated trauma centre than at non-trauma
centres10 . However non-trauma centres were dened as
large hospitals that managed 25 or more trauma patients a
year and the presence of on-site specialist surgical services
was not stipulated. Another recent study compared patient
outcomes for 3-year periods either side of designation as
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a level 1 trauma centre. The authors did not identify an

improvement in mortality, although multivariable analysis
suggested a 31 per cent improvement in odds of death after
severe trauma when deaths in the emergency department
were excluded34 . A Canadian study that examined
outcomes after institution of a trauma service, trauma unit
and performance improvement programme consistent with
Canadian accreditation criteria was also unable clearly to
demonstrate a signicant improvement in overall survival
or length of stay, although there was a suggestion of
improved survival in certain subgroups (such as those
with severe blunt trauma)35 . A more recent study has
demonstrated a small but signicant reduction in mortality
rate (8 per cent) from severe injury following institution
of a full-time trauma service36 . The present study has
demonstrated a clear improvement in hospital outcomes
and quality of care following the institution of a specialist
trauma service. The magnitude of this improvement
is greater than that which most previous studies have
reported. It is unclear whether this large improvement
reects poor starting conditions and absence of a regional
trauma system, or is the result of the scope and depth of
changes introduced at the RLH over the study period.
There is strong evidence that the introduction of
a trauma system to a regional population improves
outcomes from major trauma7 10 and is able to reduce
the preventable death rate to very low levels within a
short space of time11 13 . A regional trauma system assures
the optimal delivery of trauma care to its designated
population, including the timely access to specialist care for
patients requiring transfer to trauma centres. Delays in the
transfer of severely injured patients are associated with poor
outcome37 , with haphazard arrangements present across
England and Wales5 . The RLH functions as a trauma
centre for its wider population. It accepts trauma patients
without question from the local network hospitals through
a single point of contact in the emergency department.
This helps avoid delays associated with the availability of
critical care beds and in identifying accepting teams. The
effect of this policy is reected in the 53 per cent lower
mortality rate for patients requiring secondary transfer
than the national average, and survival rates equivalent to
those of patients arriving directly from prehospital services.
There are several limitations to the study, primarily
related to the nature of the data sets examined. On
a national level, the TARN data set comprises only
480 per cent of AH in England and Wales. The
improvements in survival demonstrated at MSH may be
a reection of dropout of less active or interested units
rather than a real improvement in trauma outcomes. The
TARN England and Wales data set does not collect data
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Multidisciplinary trauma services

115

on trauma patients admitted for less than 3 days. For

the RLH and other MSH, the England and Wales data
are therefore from a more severely injured subset of all
admitted trauma patients and so does not describe the full
trauma workload or outcomes of a specialist trauma centre.
Furthermore, severely injured patients initially admitted
to AH and subsequently transferred to a higher level of
care are tracked through the system only if both hospitals
are participants. Overall outcomes for all patients admitted
to AH are therefore likely to be worse than those in the
TARN data set.
There are also differences in the case mix between the
databases. Compared with patients admitted to MSH, the
RLH population was more severely injured, more likely
to be shocked, and there were higher rates of severe brain
injury and penetrating trauma. The Ws model is weighted
for these variables and is able to account for this casemix variation. However, for mortality comparisons each of
these conditions carries a higher case fatality rate3 and so
would be expected to skew the results in favour of other
multispecialty units. The same consideration applies to
the differences in patient population between the England
and Wales and USA data sets. In addition, compared with
2000 gures, in 2005 patients admitted to the RLH were
more severely injured, with a greater proportion in shock
or having suffered penetrating injury. Thus the benets of
the trauma service may be greater in real terms than those
identied.
It is also possible that the improvements identied are
the result of the increase in trauma volume rather than
specically the result of changes in practice. Although
the number of patients from the RLH in the TARN
data set was consistent over the study, this centre
experienced a 25 per cent year-on-year increase in activity.
Previous studies have equated higher trauma case volume
with improved survival and reduced length of stay38,39 .
However, it is not clear whether this is simply a matter
of numbers or whether a higher-intensity workload results
in changes in practice and evolution of specialization that
lead to the observed improvements.
National mortality rates for severely injured patients
remain unacceptably high and there has been little or
no improvement since 19944 . The mortality rate among
major trauma patients is up to 70 per cent worse if they are
managed at a hospital without the immediate availability of
appropriate specialty surgical services. For almost 50 years,
multiple reports have recommended that trauma care be
regionalized to specialist centres15 19 . There is a tendency,
however, to equate the simple presence of on-site surgical
specialties as sufcient for designation as a trauma centre.
Experience from the RLH shows that this alone does

not result in improved outcomes. The delivery of optimal

trauma care requires specialist understanding of the trauma
involved, combined with the ability to provide complex and
time-dependent multidisciplinary care. Without expert
oversight assured through a performance improvement
programme40 and an integrated approach to care, clinical
errors and delays in the process of care are common and
lead to complications and excess mortality28 .
Implementation of a specialist trauma service and
performance improvement programme is associated with
rapid reductions in mortality for the severely injured.
Future national major trauma centres should be specialist
hospitals, not simply hospitals with specialties.

Copyright 2010 British Journal of Surgery Society Ltd

Published by John Wiley & Sons Ltd

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Acknowledgements

The authors thank Dr J. Goosen and Dr J. McLeod for

their assistance in external peer review of trauma mortality
at the RLH. The authors declare no conict of interest.
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Giant choledochal cyst

A 17-year-old woman presented with a 2-week history of mild abdominal pain and
obstructive jaundice. She had a large, tender mass between the right costal margin and
anterior superior iliac spine. MRI demonstrated a large cystic lesion which communicated
with the cystic duct and was indistinguishable from the common bile duct (Fig. 1a).
At laparotomy, there was a massive choledochal cyst extending from the ampulla of Vater to
the bifurcation of the left and right hepatic ducts. This cyst contained 2200 ml of bile. A
choledochectomy was performed en-bloc with a Whipples procedure (Fig. 1b). Pathological
examination revealed the benign Type I choledochal cyst.

Pylorus
Choledochal cyst
Gallbladder

Choledochal cyst

Head of pancreas
Duodenum

Gunn V, Adeyi O, Jhaveri K, Wei AC: Toronto General Hospital and University of Toronto, Toronto, ON, Canada
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Copyright 2010 British Journal of Surgery Society Ltd

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British Journal of Surgery 2010; 97: 109117