trauma & emergency surgery organisation of hospitalar...
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Trauma & Emergency Surgery – Organisation of Hospitalar Response in Portugal and EU
Carlos Mesquita Coimbra – Portugal
“O Cirurgião Barbeiro” – Jacobus de Cessolis, séc. XV
HOSPITAIS DA UNIVERSIDADE DE COIMBRA SERVIÇO DE URGÊNCIA
POPULAÇÃO R. CENTRO: > 2000.000 h
URGÊNCIA HUC (ADULTOS):
• Admissões / ano > 160.000 > 450 / d
• Internamentos / ano > 16.000
> 45 / d
• Emergências / ano > 1.600 > 4-5 / d
• Interv. cirúrgicas / ano > 3.600 = 9-10 / d
Doença Interna 120.286
Quedas 8.790
Outros 7.231
Acidentes de Trabalho 4.663
Acidentes de Trânsito 2.209
Intoxicações 1.241
Agressões 1.150
Acidentes Escolares 829
Acidentes Desportivos 434
Total / ano 18.075 1.241 7.231 120.286 146.833
Total / dia 50 3 20 330 403
12 % 1 % 5 % 82 %
SERVIÇO DE URGÊNCIA– Admissões / ano
CIRURGIA GERAL – 220 camas
• 3 serviços (o terceiro no HG)
• 1 unidade de transplantação hepática
• 1 unidade de cuidados cirúrgicos intermédios (apoia outras especialidades)
URGÊNCIA CIRÚRGICA
• 2500 internamentos / ano – 7 / dia = ocupação média de 60-70 camas, um terço
• 1800 intervenções/ano – 5 / dia = 30 %, quase um terço da actividade operatória global
CIRURGIA GERAL E CIRURGIA DE URGÊNCIA
EMERGENCY SURGERY
Others 306 - 20 %
Sepsis 810 – 53 %
Trauma 413 - 27 %
CM, n=1529, 31 years (1982 – 2012)
ASPECTOS NEGATIVOS:
• bloco operatório dedicado apenas de manhã (08 -16) e nos dias úteis
• reflexos previsíveis na eficácia dos procedimentos de controlo de dano
• atribuição de significado clínico aos fluxogramas da Triagem de Manchester e delegação de competências em não médicos como forma de contornar a falta de investimento numa triagem médica qualificada
• área cirúrgica transformada num desdobramento da urgência básica
• equipa cirúrgica forçada a dispersar a atenção por um número de doentes mais de 10 vezes superior ao expectável
• consequente quebra de qualidade no atendimento dos doentes cirúrgicos
• internos de Cirurgia Geral no papel de generalistas e recorrentemente impedidos de ir ao bloco operatório, face ao volume de doentes a aguardar uma primeira observação
CIRURGIA GERAL E CIRURGIA DE URGÊNCIA
O que está no RI Artigo 23.º Comissão de Trauma 1. À Comissão de Trauma (CT) compete em geral promover a otimização de
todos os aspetos relacionados com os cuidados a prestar ao doente traumatizado, segundo o estado da arte e as disposições normativas de boas práticas.
2. A CT é multidisciplinar e constituída por sete membros, nomeados pelo Conselho de Administração. O seu presidente é o coordenador médico do Centro de Trauma - CHUC.
3. A CT pode agregar outros elementos sempre que julgue necessário. 4. A Comissão deve reunir pelo menos mensalmente, sem prejuízo de o
poder fazer sempre que for convocada pelo seu presidente ou por pelo menos quatro dos seus membros.
5. À CT compete, designadamente: a) Elaborar e desenvolver o programa interno de trauma do CHUC como
centro de trauma nível um, que contemple questões organizativas, de articulação com outras entidades, de orientação terapêutica, de formação e de melhoria da qualidade.
b)Acompanhar a aplicação da legislação ou normas orientadoras, nomeadamente no domínio da “Via Verde do Trauma” e apoiar a direcção do Serviço de Urgência em tudo o que lhe diga respeito;
c) Discutir e pronunciar-se sobre as boas práticas, respeitando as regras deontológicas, na assistência ao trauma, incluindo a revisão de óbitos em trauma;
d)Criar, implementar e manter o registo de trauma no CHUC; e)Desenvolver o programa de avaliação e melhoria da qualidade na
abordagem e tratamento do doente traumatizado; f) Integrar a Comissão Regional de Trauma e participar na discussão das
matérias relacionadas com a rede local, regional e nacional de trauma;
g) Contribuir, sempre que solicitado, em programas de prevenção da sinistralidade por trauma.
O que não está no RI (o que foi deixado de fora…)
• Determina a estrutura do Sistema Integrado de Emergência Médica (SIEM) ao nível da responsabilidade hospitalar e sua interface com o pré-hospitalar, os níveis de responsabilidade dos serviços de urgência (SU), estabelece padrões mínimos e define o processo de monitorização e avaliação
• No que especificamente, se aplica a adultos e a Centros de Trauma, enquanto polos duma rede nacional de tratamento do politraumatizado grave, prevê
1. que devam possuir heliporto ou ter acesso fácil a um
2. que funcionem numa lógica de centralização de recursos altamente diferenciados, assegurando a prestação de cuidados de saúde no âmbito das seguintes valências, além das obrigatórias para um SUP:
• Radiologia de intervenção
• Cirurgia Cardiotorácica
• Cirurgia Maxilofacial
• Cirurgia Plástica e Reconstrutiva
• Cirurgia Vascular
DESPACHO 10319/2014, DE 11 DE AGOSTO
4. que constituam referência para os doentes a incluir na Via Verde Trauma
5. que a formação e o currículo de 100% dos profissionais em exercício passe a contemplar o suporte avançado de vida em trauma (SAVT)
• que esta formação esteja concluída em três anos
6. que a formação e o currículo de 100% dos profissionais em exercício passe a contemplar o reconhecimento de Competência em Emergência Médica pela OM
• que este reconhecimento esteja concluído em cinco anos
DESPACHO 10319/2014, DE 11 DE AGOSTO
• Tendo em conta, entre outras, as recomendações da DGS e da OM, haverá que compreender o SAVT não apenas como um curso mas, de modo mais abrangente, como um conjunto de modelos de mais do que um nível, orientados para grupos e subgrupos profissionais diferentes, reconhecidos internacionalmente e bem divulgados em Portugal, designadamente
• ATLS, para médicos generalistas
• MRMI, para intervenientes na resposta ao desastre e catástrofe
• ETC, para membros das equipas hospitalares de trauma
• DSTC, MUSEC e EASC, para cirurgiões
• DATC para anestesistas
• DPNTC, para enfermeiros do bloco operatório
DESPACHO 10319/2014, DE 11 DE AGOSTO
• patient’s survival dependent on the trauma team working effectively rather than the abilities of any one individual
• your role in the team will change depending on the needs of the patient
• by the end of the course you will have improved your knowledge, skills and abilities as a team member and team leader
• you will then understand how all of these enhance team performance and ultimately contribute to improving patient outcome
EUROPEAN TRAUMA COURSE (ETC) TRAUMA CARE, THE TEAM APPROACH
?
? ? ?
? ? • 26 Major Trauma Centres
• Population > 54,000,000
April 2012 UK Government announced creation of major
trauma centres
• Trauma team
• ISS > 15 assessed by consultant within 5 minutes
• CT scan < 30 minutes
• CT scan reported < 60 minutes
• Consultants available on site within 30 minutes when required:
Neurosurgery
Spinal and spinal cord surgery
Vascular surgery
General surgery (adult or child)
Trauma and Orthopaedic surgery
Cardiothoracic surgery
Plastic surgery
Maxillofacial surgery
Ear nose and throat surgery
Anaesthetics
Interventional radiology
Intensive care
In most European countries, a progressive focus on planned activities at the expense of the urgent, has undermined the ability of surgeons in general to intervene in emergency situations outside their area of specialization
• This is even more important when governments and institutions maintain medical missions in theaters marked by underdevelopment, political instability or even war
To bring emergency surgical care into line with the modern world, it is essential to redesign our training curricula
• standards of care for emergency surgical admissions often unsatisfactory
failure to prioritize patients
inadequate senior input
unsatisfactory allocation of infrastructure and manpower
• emergency surgery characterized as the ‘Cinderella Service’
Association of Surgeons of Great Britain and Ireland (2007):
• multicentre audit to measure non-risk-adjusted outcome after emergency laparotomy in order to establish a baseline
• data from 1853 patients were collected from 35 NHS hospitals • mortality rates varied from 3.6% to 41.7%; unadjusted 30 day
mortality was 14.9% for all patients and 24.4% in patients aged 80 or over
• clinicians asked to collect prospective anonymized data for a period of 3 months
• data set included a description of patient characteristics, timing of surgery, grade of clinical personnel in theatre, anatomical site of surgery, operative procedure, postoperative destin- ation, length of stay and 30 day mortality
• analysis of the pooled data returned to contributors, allowing them to identify and reflect upon their own outcomes
Possible solutions
• protocols & pathways
• networks
• non-medical roles
• new training models
Watson R, Crump H, Imison C, Currie C and Gaskins M (2016) Emergency general surgery: challenges and opportunities. Research Report. Nuffield Trust.
• Emergency general surgery (EGS) represents 11% of surgical admissions and 50% of surgical mortality in the United States. However, there is currently no established definition of the EGS procedures
• a final set of 7 operative EGS procedures were identified, which collectively accounted for 80.0% of procedures, 80.3% of deaths, 78.9% of complications, and 80.2% of inpatient costs nationwide
• these 7 procedures were partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy
JAMA Surg. doi:10.1001/jamasurg.2016.0480. Published online April 27, 2016
• the term ‘Emergency General Surgeon’ is now becoming familiar in the UK but, however, EGS remains an unrecognised UK training subspecialty without a separate higher surgical training programme or modular competency based assessment.
• UK higher surgical training programmes have not sought to address potential short falls in emergency general surgical training, and competencies or encouraged trainees to pursue a career in EGS
• EGS training remains acquired during out of hours service provision (limited by European Working Time Directive) on an ad hoc basis, is not standardized and a workforce gap has been created
PROPOSAL TO ESTABLISH A EUROPEAN
QUALIFICATION OF COMPETENCE IN TRAUMA
AND NON-TRAUMA EMERGENCY SURGERY
Carlos Mesquita, Renato Bessa de Melo, Fernando Ferreira, Ricardo Pereira, Jorge Pereira, Luís Filipe Pinheiro, Henrique Alexandrino, Mário Mendes, Pedro Ramos, António Figueiredo, Arnaldo Figueiredo, João Paulo Farias
Working Group for Emergency Surgery of the Portuguese Medical Association (GTFCE-OM)
Ordem dos Médicos GT Cirurgia de Emergência
Ordem dos Médicos – Grupo para a Formação em Cirurgia de Emergência
Sociedade Portuguesa de Cirurgia - Capítulo de Trauma
Associação Lusitana de Trauma e Emergência Cirúrgica
ESTES - Visceral Trauma & Emergency Surgery Sections
IATSIC - National Steering Group for DSTC
WSES – World Society of Emergency Surgery
ACS - American College of Surgeons
1. TRAUMA AND SURGICAL INTENSIVE CARE 06 months
Participation in Trauma Teams
Pre and postoperative treatment of complex surgical conditions, in high dependency
care setting
03 (or 520
hours)
03
1. ELECTIVE AND EMERGENCY SURGERY 18 months
General Surgery 06
Cardiothoracic Surgery 02 (1/3)
Angiology and Vascular Surgery 02 (1/3)
Orthopedics 02 (1/3)
Optional: Transplantation Surgery (including harvesting of abdominal and thoracic
organs), Gastrointestinal endoscopy, Interventional Radiology, Pediatric Surgery, Plastic
Surgery and Burns, Neurosurgery, Urology, Gynecology and Obstetrics and others, or
maximization of time in nuclear traineeships
06 (4/8)
1. COURSES:
Advanced Life Support (ALS, ERC) or equivalent
Essential
Advanced Trauma Life Support (ATLS, ACS) or equivalent Essential
Fundamental Critical Care Support (FCCS, SCCM) or equivalent Desirable
Definitive Surgical Trauma Care (DSTC, DSTS, IATSIC) or equivalent Essential
Emergency Surgery Course (ESC, ESTES) or equivalent Desirable
Modular Ultrasound ESTES Course (MUSEC, ESTES) or equivalent Essential
TRAINEESHIPS AND COURSES Should constitute initial standards the existing training programs in related areas for residents of the various surgical
specialties and the courses listed in this table. However, if the acquisition of specific skills is obtained by other means, including accredited simulation environment, the frequency of the corresponding stages or courses can be dispensed
ANATOMICAL AREA / PROCEDURE ESSENTIAL DESIRABLE
1. AIRWAY
Nasal and oral endotracheal (including rapid sequence) intubation X
Cricothyroidotomy, open and percutaneous X
Tracheostomy, open and percutaneous X
1. SKULL / FACE
ICP monitoring X
Trepanation / Craniotomy X
Nasal packing X
1. NECK
Approach and control of vascular and aerodigestive lesions X
1. THORAX
Damage control techniques, eg aortic clamping X
Approach and control of cardiac lesions and cardiac tamponade X
Approach and control of vascular lesions X
Approach and control of aortic injuries in blunt trauma X
Approach and control of tracheobronchial and pulmonary lesions X
Surgical treatment of infections and empyema X
Surgical treatment of diaphragmatic injuries X
Bronchoscopy: diagnostic and therapeutic X
Approach and control of esophageal lesions X
Video-assisted surgery in relation to the procedures performed X
ACQUISITION OF TECHNICAL COMPETENCES The technical capabilities herein should preferably be obtained in a clinical context. However, simulation training in an
accredited environment, if plausible, can be an alternative
1. ABDOMEN AND PELVIS
Damage control techniques (including pelvic stabilization) X
Approach and control of vascular lesions X
Approach and control of digestive tract and attached organs lesions X
Approach and control of kidneys and urinary tract X
Approach and control of female genital lesions (including pregnancy) X
Approach and control of abdominal sepsis X
Treatment of necrotizing soft tissue lesions X
Approach and control of abdominal compartment syndrome X
Techniques for abdominal wall reconstruction X
Video-assisted surgery in relation to the procedures performed X
1. EXTREMITIES
Imobilization of fractures and dislocations and application of tractions and external fixators
X
On-table angiography X
Approach and control of vascular lesions X
Thromboembolectomies X
Vascular access techniques in context of Extra Corporeal Life Support X
Fasciotomies X
Treatment of necrotizing soft tissue lesions X
Amputations X
1. OTHERS
Plastics and skin grafts (including burns) X
Hypothermia treatment techniques X
Upper and lower gastrointestinal endoscopy X
Diagnostic Ultrasonography X
Therapeutic Ultrasonography X
To be considered for the award of an Honorary FEBS(EmSurg) diploma a candidate must:
1. To have been a consultant surgeon (or equivalent) dealing with emergency surgical admissions for a minimum of 10 years
2. To have taught on a nationally or internationally recognised course directly relevant to emergency surgery within the preceding 5 years
3. To have at least one publication in the field of emergency surgery published in a peer reviewed journal during the preceding 2 years
4. To have presented to at least one major national or international meeting in the preceding 2 years
5. To have contributed to the development of emergency surgery at a regional, national or international level
HONORARY DIPLOMA – EMERGENCY SURGERY
BOARD EXAMINATION – EMERGENCY SURGERY
To apply for Eligibility the candidate must fulfill the following requirements:
1. To have been trained in one of the 28 European Union countries, a UEMS country (Iceland, Norway and Switzerland), an associated UEMS country (Armenia, Israel and Turkey) or a country with UEMS observer status (Georgia, Lebanon and Morocco)
2. To have been trained outside the UEMS area provided that the training and qualifications are equivalent
3. To be able to communicate in the English language. Examinations in the local national language(s) may also be provided at the discretion of the executive
4. To have a national Certificate of Completion of Specialist Training
5. To provide a logbook listing the own experience of the required operations and procedures, as published in "Emergency Surgery Curriculum - Skills“. For each procedure the date it was performed, patient's initials (or hospital admission number) and type of independent expert must be provided. Must not contain patients' names
6. All candidates should have successfully completed the Advanced Trauma Life Support (ATLS®) provider course. As an alternative, to provide satisfactory evidence within their logbook of the procedures listed in Category E
7. Candidates should have completed the Definitive Surgical Trauma Care (DSTC®) course or an approved alternative, (i) the Definitive Surgical Trauma Skills (DSTS®) course or (ii) both the Advanced Trauma Operative Management (ATOM®) and the Advanced Surgical Skills for Exposure in Trauma (ASSET®) courses. As an alternative, to provide satisfactory evidence within their logbook of the procedures listed in Category F
8. All candidates must have contributed to a published scientific paper for which they are listed as a co-author
BOARD EXAMINATION – EMERGENCY SURGERY
9. The candidate must have a total of 12 credit points based on the following criteria:
• Participation at recognized international congress (e.g. European Society for Trauma and Emergency Surgery (ESTES) or American Association for the Surgery of Trauma (AAST) (4 points)
• Participation at recognized international congress (e.g. ESTES or AAST) and first authorship of an accepted paper or poster (8 points)
• Participation national congress (2 points) • Participation at national congress and first authorship of an accepted
paper or poster (4 points) • Publication (first authorship) in peer reviewed national surgical journal
(8 points) • Publication (first authorship) in peer reviewed international surgical
journal (12 points) 10. Candidates must be recommended by 2 independent experts, one of which
must not currently work in the same region as the candidate
BOARD EXAMINATION – EMERGENCY SURGERY
The minimum requirement for eligibility for assessment is a certified number of 550 credit points for the listed procedures All the credit points from Category A and at least 150 credit points from Categories B, C and D must be achieved as principal surgeon
EMERGENCY SURGERY SKILLS