Regional trauma system development in Shenzhen, China: an 8-year journey


 Background: International experiences have shown that trauma system development significantly reduces preventable deaths and disabilities. During the 8-year study, the aim was to find solutions for trauma system development in Shenzhen, China, so as to reduce trauma mortality and morbidity. Methods: Introducing the ATLS® program to mainland China was started in 2013. A geospatial analysis of traumatic incidents was conducted in 2014. A regional trauma center was illustrated as an example to be used as a reference. The trauma audit meeting was introduced as an approach to continuous trauma quality improvement. The Shenzhen Trauma Surgery Committee was established to finalize the plan for designation of trauma care hospitals. The American College of Surgeons Trauma System Development Guidelines were translated into Chinese. Results: ATLS® provider course was held in Shenzhen and totally 205 doctors received training. A regional trauma center where adopted ATLS® principles as the standard for trauma resuscitation and early trauma care, with results showing significant improvements in trauma team organization, trauma resuscitation, definitive trauma care and a significant reduction in mortality among major trauma patients. The trauma audit meeting was introduced to 8 hospitals. A new trauma system plan for Shenzhen was set up and a consensus was reached on trauma center designation. The American College of Surgeons' “Resources for Optimal Care of the Injured Patient” was translated into Chinese and published in November 2020. Conclusion: The critical steps in establishing the framework for the Shenzhen trauma system included: geospatial analysis of traumatic incidents, trauma care training for providers, trauma center development, regional trauma center designation and development of trauma quality improvement programs. This practical approach can be replicated in other countries seeking to establish a trauma system. We are now working toward extension of this approach to other regions of mainland China.


Introduction
According to the World Health Organization, injuries account for 9% of global mortality and road tra c injuries alone will become the fth leading cause of death in 2030 [1,2]. It is estimated that by 2030, annual and cumulative GDP losses in low-and middle-income countries affected by injuries will be the second leading causal factor, accounting for losses of up to US$0.6 trillion annually [3]. Since the late 1980s, trauma in China has been identi ed a major public health challenge, and today, tra c-related fatalities account for 80% of accidental deaths. Since the mid-1990s, deaths caused by tra c accidents alone have been estimated at ranging from 200,000 to 400,000 persons per year [4]. China's National Health Commission released a guideline in June 2018 calling for the development of trauma centers and trauma systems across mainland China [5].
As de ned by Prof. Hoyt and Prof. Coimbra, a trauma system is an organized approach to severely injured patients. It should occur within a de ned geographic area and provide optimal care that is integrated with the local or regional emergency medical services (EMS) system [6]. The trauma system has been widely reported to reduce trauma-related mortality, including preventable trauma deaths [7][8][9][10]. A famous study by MacKenzie et al. [7] showed that the mortality rate of severely injured patients could be reduced by 25% if they were treated in a trauma center as opposed to a non-trauma center institution. Prof. Maier noted in his presidential address at the 61st Annual Meeting of the American Association for the Surgery of Trauma in 2002 that "The number of Level I and Level II trauma centers should be based on the needs of patients; duplication of high-level trauma centers dilutes the patient volume and leads to unreasonable competition and resource allocation. It also limits the trauma science development capacity of the region [11]." Located in southeastern China, Shenzhen was designated as China's rst Special Economic Zone in in 1979 and has now become one of the best economic cities in China and one of the fastest growing cities in the world. In 2019, Shenzhen had a total population of approximately 20 million with 10.8 million residents and a further 9 million residents in the surrounding metropolitan area [12]. During the period of 2010-2017, both emergency medical services and the total number of trauma patients in Shenzhen had been on the increase, with trauma accounting for 47.0% and 38.4% in 2010 and 2017, respectively [13]. A study [14] conducted in 2015 showed patients who were considered to have suffered major trauma, from the scene to the hospital, as 8.5% were taken to a university teaching hospital, 13.6% to a regional general hospital, 42.6% to a public community hospital and 35.3% to a private hospital. The prehospital system in Shenzhen was sending trauma patients to the nearest hospital, which has resulted in some major trauma patients being sent to hospitals that do not have adequate resources and treatment capacity.
Trauma has been increasingly recognized as a major public health issue in Shenzhen. Experiences from the international trauma community have shown that trauma system development signi cantly reduces preventable trauma deaths and disabilities. The main components of a trauma system include trauma care training for providers, trauma center development, regional hospital-designated trauma care, and trauma quality improvement programs. This report describes the efforts to implement these programs and establish a trauma system in Shenzhen, China from 2013 and 2020.

Introducing the ATLS ® program to mainland China
In September 2013, with the authorization of the American College of Surgeons (ACS), a team including faculty from the ACS China-Hong Kong Chapter and the University of Hong Kong-Shenzhen Hospital (HKU-SZH) was established. The process included organizing a team to translate the ATLS ® Student Manual (9 th edition) into Chinese, establishing a surgical skills center in HKU-SZH for ATLS ® teaching, training Chinese Mandarin-speaking ATLS ® instructors from Shenzhen, and changing the language of ATLS ® teaching from English courses to English-Chinese hybrid courses, followed by Chinese courses.
Performing geospatial analysis of traumatic incidents in Shenzhen incidents in Shenzhen and to help design and designate trauma care hospitals. Data were obtained from the Shenzhen "120" EMS center, which records information on all patients requiring an ambulance during pre-hospital care. The EMS registry recorded both diagnoses and incident locations as electronic free text. Virtually all injury-related diagnoses contained the word " " (injury), which facilitated the identi cation of incidents involving trauma. Anonymized information was extracted, including demographic and physiological data, diagnoses, other necessary clinical details, and incident location. To further evaluate the geographical distribution of incidents, a combination of automated (http://www.gpsspg.com/xGeocoding/) and manual geocoding (using Google maps) was used to geocode the incident location free text elds to longitude and latitude. Establishing a Regional Trauma Center A Regional Trauma Center was formally established in HKU-SZH on November 30, 2018 in order to provide better trauma services for local trauma patients and to serve as a reference for other hospitals in Shenzhen. The trauma center adopted ATLS ® principles as the standard trauma resuscitation process for early trauma management, including the MIST handover process between pre-hospital care and the emergency department, ABCDE priority principles for trauma resuscitation, bedside chest and pelvic X-ray, FAST examination, and a team approach. A multidisciplinary trauma team was established to provide formal trauma services, with the rst layer comprising a general surgeon, ED physician, orthopedic surgeon, ICU doctor, radiologic technician, three trauma nurses and other well-trained colleagues. A trauma ward was also established within the general surgery ward. Important protocols and trauma service manuals were developed, including early Type "O" blood transfusion, massive transfusion protocol, and management protocol for severe pelvic injuries that are hemodynamically unstable.

Trauma audit program
The trauma audit meeting has been introduced as a way to improve the quality of trauma in HKU-SZH at the time of establishing the trauma center. Meetings were organized on a regular monthly or bi-monthly basis. During the meetings, trauma management ow, decision making and trauma management skills were reviewed for each trauma death and for any major trauma patients who may have made errors or mistakes in the management process. Data were collected to compare trauma preventable deaths before and after the trauma center was established. A group of eight hospitals led by HKU-SZH applied to establish a trauma academic organization in Shenzhen in December 2019. The purpose of this organization is to organize and improve trauma academic activities in Shenzhen and to involve the major trauma service hospitals. Meanwhile, the Shenzhen Health Commission organized an expert panel meeting on the development of trauma centers in Shenzhen and discussed plans for designating trauma care hospitals based on the traumatic incident location, hospital location, hospital level, previous trauma patient volume and trauma care resources.
Baseline information regarding different trauma care hospitals was collected to develop criteria for regional trauma center and trauma care hospitals.

Introducing trauma team into Shenzhen
The Shenzhen Health Commission has established a program to introduce renowned medical teams to

ATLS ® program in mainland China
The ATLS ® Student Manual was translated into the Chinese version by a team from HKU-SZH. The Chinese version was published by People's Medical Publishing House Co., Ltd in August 2016. The rst ATLS ® provider course was held at HKU-SZH in September 2016. By September 2020, a total of 205 doctors from 6 provinces in China had received ATLS ® training at HKU-SZH. Table 1 shows which city and department the students came from. A questionnaire survey was sent to 121 students in October 2018 and 103 respondents were received. The study showed that 96.1% of the respondents found the ATLS ® course helpful in clinical work, 87.3% found the ATLS ® course in uential in deciding whether to intubate a patient, 86.4% found the ATLS ® course in uential in chest tube insertion and 85.4% found the ATLS ® course in uential in resuscitating a traumatic shock patient. Establishing a regional trauma center as a model A Regional Trauma Center was o cially established in HKU-SZH on November 30, 2018, which has adopted ATLS ® principles as the standard for trauma resuscitation and early trauma care, with results showing signi cant improvements in trauma team organization, trauma resuscitation, de nitive trauma care and a signi cant reduction in mortality among major trauma patients. In 2018, a total of 1913 trauma patients were admitted to HKU-SZH, including 82 major trauma patients (ISS>15 or activated multidisciplinary trauma team). There were 8 trauma deaths, accounting for 9.8% of major trauma patients, and 1 patient with preventable trauma death was recognized based on regular trauma audit meetings. In 2019, HKU-SZH admitted 1919 trauma patients, of which 153 were major trauma patients (ISS>15 or activated multidisciplinary trauma team). There were 5 trauma deaths, accounting for 3.3% of major trauma patients, and 1 potentially preventable trauma death was recognized based on regular trauma audit meetings ( Table 2) Geospatial analysis of trauma incidents and establishment of trauma networks A total of 49082 trauma patients were found between January 01, 2014 and December 31, 2014. Of these patients, 3513 (7.1%) were retrospectively classi ed as having met the criteria for either Step 1 or Step 2 of the Field Triage Decision Scheme (FTDS) and were therefore likely to have suffered a major trauma. Fig. 1 shows a dot map of the geographical distribution of trauma incidents and hospitals receiving trauma patients. Incidents are mostly concentrated in the western and central part of Shenzhen, bordering Hong Kong. The nearest neighbor index was 0.048, indicating a high degree of clustering.
The Shenzhen Trauma Surgery Committee under CMDA was o cially approved and established in June 2020. The committee includes almost all hospitals that receive trauma patients and Shenzhen EMS. The committee has already conducted six hospital visits with the aim of reviewing trauma service processes and management ow, and identifying challenging parts of the hospitals visited so that further actions can be taken to address the trauma care de cit. A few committee meetings were arranged and the trauma system development in Shenzhen was discussed with the support of the National Center for Trauma Medicine (NCTM) in Beijing. The Shenzhen Trauma System was developed using NCTM's regionalization and "1+X" concept. Six regional trauma networks were recommended by the committee and one leading hospital in the regional network is being used for trauma clinical care (Fig. 2). Except for clinical trauma care, HKU-SZH is being recommended as the tertiary trauma teaching and training hospital in Shenzhen.

Trauma quality improvement program in Shenzhen
When the Trauma Center was established in November 2018, trauma audit meetings were introduced as an approach to improve the quality of trauma at HKU-SZH. This has proven to be an effective way to identify de ciencies in the trauma care process, as well as to identify measures for improvement. The author's institutional study on preventable deaths in multiple trauma patients [15] was published in February 2020, and it recommended that every trauma care hospital should adopt some approach to continuously improve its trauma care, and the trauma audit meeting is one of the recommended approach. Since July 2019, this program has been introduced to other hospitals in Shenzhen and propagated to seven other hospitals in late 2019. Today, many trauma care hospitals in Shenzhen have made reference to this program and have established their own methods and policies to improve trauma care. A further multicenter study on preventable deaths in major trauma patients has been planned and is being conducted in Shenzhen, which will reveal results in Shenzhen over the next two years. Prof. Maier and his colleagues found that the effect of regionalization on mortality from motor vehicle accidents reduced the risk of death by 8%, but it took over 10 years for this to manifest itself. Although it is likely that a gradual process of quality improvement was observed, signi cant reductions in traumarelated mortality were not measurable until several years after implementation of the trauma system [17]. The great ambitious goal of the United States since April 2017 has been to establish a national trauma system and achieve zero preventable trauma deaths nationwide [18][19]. Trauma training is the foundation for trauma care. ATLS ® has been developed by the ACS COT for over 40 years and has driven the development of trauma science worldwide. One of the most important characteristics of the ATLS ® course is its strict and high quality teaching. The small class, usually 16 students per class, is the standard arrangement. In the past decade, trauma training has been in high demand in China, and ATLS ® was not introduced in mainland China until September 2016, so China has developed its own trauma course, "China Trauma Care Training (CTCT ® )", to provide the necessary trauma knowledge and skills training for medical and nursing personnel who take care of trauma patients. As mentioned above, ATLS ® was introduced to mainland China in September 2016, and a total of 205 providers have received training from the author's institution. Looking to the future, the CTCT ® and ATLS ® courses will assume primary responsibility for providing trauma care training to medical and nursing personnel in mainland China. As stated by Prof. John Wong, "...perhaps, those who wish to receive local trauma training using CTCT ® , and those who wish to receive the international standard trauma care course using ATLS ® …" In the author's institution, the mortality rate patients with major trauma in 2019 was signi cantly lower than that in 2018, which was mainly due to the organization of the multidisciplinary trauma team and the formal establishment of the trauma center in November 2018. All trauma team members received ATLS ® training and the ATLS ® "common language" was adopted as an early management principle. The timely response of the trauma team and the well-organized trauma resuscitation and following de nitive care play a major role for the improvement of trauma quality.
internationally [21][22][23][24][25]. Such studies can identify the distribution characteristics of trauma incidents in a particular region or country, as well as the distribution of trauma care resources. It is a very useful approach to nd a reasonable timeline for a particular trauma incident in a region. It can be presented as a heat map and can easily demonstrate the appropriateness of a regional trauma system framework to medical personnel, health and government o cials, and policy makers. Mainland China is still in the early stages of trauma center and trauma system development, and the rationale for such a study would be very helpful for trauma system design, especially in providing invaluable information for a region to consider its new trauma system con guration. A similar study was carried out in Shenzhen in 2015, and the outcomes of the study were published in 2017 [14]. These outcomes have been adopted as one of the new Shenzhen trauma system design guidelines.
The World Health Organization and the International Association for Trauma Surgery and Intensive Care's "Guidelines for trauma quality improvement programs" (WHO, 2009) [26] state that techniques for improving trauma quality include 1) morbidity and mortality (M&M) conferences, 2) preventable death panel reviews, 3) tracking of audit lters, complications, errors, adverse events, and sentinel events, 4) statistical methods: risk-adjusted mortality, 5) corrective strategies and closing the loop, 6) system-wide and pre-hospital quality improvement, 7) role of medical records and trauma registries, 8) appropriateness of using different techniques at different levels of the health care system. Although the concept of trauma auditing and the audit process is new in mainland China, every hospital in mainland China has long adopted a policy based on "discussion of death and di cult cases". Despite the differences in the process and format of the discussion, the rationale behind it is virtually the same. The trauma audit meeting process usually includes a panel from the hospital trauma committee or regional trauma committee, and reviews speci c trauma death cases or any other major trauma cases that could possibly be further improved. The review content usually includes management ow, medical decision making and appropriateness of medical skills. At the end of the meeting, every member of the committee will be required to draw a conclusion as to whether it was an unpreventable death, a potentially preventable death or a preventable death, or whether the management process was appropriate or not, and if not, where the error was/mistakes occurred. Finally, an improvement action protocol and follow-up plan will be developed for further improvement in the future work. Every hospital that takes care of trauma patients should have its own policies and programs for improving the quality of trauma. The purpose of the policy and program should be to continuously identify de ciencies or errors in the trauma care process, and then to develop the action protocol for improvement and an avoidance of recurrence of the same errors.
As mentioned above, the Shenzhen Trauma Surgery Committee has recommended six regional trauma networks. There are a number of reasons behind this. First of all, it is an inclusive trauma system, with six trauma networks covering the entire population of Shenzhen. Shenzhen EMS has 74 network hospitals, including tertiary teaching hospitals, regional general hospitals, community public hospitals and private hospitals. All of these hospitals attend to traumatic incidents and provide primary care to trauma patients.
For those hospitals without adequate trauma resources, they either transfer trauma patients from the scene to other major hospitals or, after providing primary trauma care at their own institutions, to other major hospitals if necessary. Secondly, Shenzhen is a city with a population of nearly 20 million and covers an area of 1997.47 square kilometers. Although the air ambulance system was o cially established on November 22, 2019, road ambulances are almost the only pre-hospital transfer method for trauma patients [27]. It will be reasonable and feasible for road ambulances to transfer trauma patients to the appropriate hospital within a reasonable timeframe through the six trauma networks' plans. Thirdly, each trauma network will adopt the concept of "1+X", with "1" indicating the top hospital leading trauma services for that network and "X" indicating the other hospitals within the same network. The criteria for the top hospitals will include both hard and soft criteria. The hard criteria will include trauma surgery and multidisciplinary trauma teams, trauma resuscitation bays, CT in the emergency department, trauma ICUs, trauma wards, department of rehabilitation, and all trauma team members taking care of trauma patients who have received either CTCT ® or ATLS ® training. The soft criteria will include trauma teaching and research capabilities. A new Shenzhen trauma network program is underway, which will be completed by the Shenzhen Trauma Surgery Committee. This work will be completed and submitted to the Shenzhen Health Commission by June 30, 2021. It is anticipated that the new Shenzhen Trauma System will be fully operational from January 01, 2022.

Conclusion
The critical steps in establishing the framework for the Shenzhen trauma system included: geospatial analysis of traumatic incidents, trauma care training for providers, trauma center development, regional trauma center designation and development of trauma quality improvement programs. This practical approach can be replicated in other countries seeking to establish a trauma system. The effectiveness of this study has been demonstrated and there is value in extending it to other parts of mainland China.

Declarations
Ethics approval and consent to participate Ethical approval: This study was approved by the PLA Medical College and the University of Hong Kong-Shenzhen Hospital (Reference 2016 45).

Consent for publication
Personal consent for publication obtained.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
The introduction of the ATLS ® program to mainland China was funded by the ACS China-Hong Kong Chapter. The publication of the Chinese version of "Resources for Optimal Care of the Injured Patient" (6th edition, 2014) was funded by the Chongqing Science and Technology Commission innovation project -"Application demonstration of appropriate techniques for the diagnosis and treatment of severe trauma" (cstc2017shms kjfp120009).
Author's contributions GZ developed the concept for the study, organized to obtain the data, conducted the analysis, and wrote the rst draft of the manuscript. GL assisted with data collecting, contributing to data statistics and analysis, and contributed to the writing of the manuscript, especially for the part of ATLS training. CL assisted with the data collecting, contributing to the tables, and contributed to the writing of the manuscript, including the ATLS part and the trauma clinical service part. RL assisted with the data collecting, contributing to the tables, and contributed to the writing of the manuscript, mainly for the ATLS part. JW assisted with the data collecting, contributing to the tables, and contributed to the writing of the manuscript, mainly for the ATLS part. RM assisted with the data collecting, contributing to the tables and gures, and contributed to the writing and correction of the manuscript, including the ATLS part, Shenzhen

Supplementary Files
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