Low major trauma confidence among emergency physicians working outside major trauma services: Inevitable result of a centralised trauma system or evidence for change?

Objective: Regionalised civilian trauma systems improve patient outcomes, but may deskill clinicians outside major trauma services (MTSs). We aimed to characterise experience and confidence in trauma management among emergency physicians working in MTS to those working elsewhere. Methods: Emergency physicians working within the Victorian State Trauma System were surveyed about their pre- and post-fellowship training experience, their estimated hours per fortnight in different centres, the frequency of performance/supervision of critical emergency skills and their confidence in a range of trauma skills. Results: The 138 respondents analysed represented 33% of active Victorian FACEMs. The cohort were mostly males (69.6%), younger than 50 (75.4%) and were generally (69.6%) six or more years post-fellowship. FACEMs working in a MTS were more likely to have been a trauma registrar prior to fellowship (13.3% vs 3.7%, P = 0.046). MTS clinicians performed more, supervised more and were more confident in trauma team leading, traumatic airway management and rapid infusion catheter and multi-access catheters. Confidence in trauma team leading was only associated with exposure to performance or supervision of trauma team leading. Performance of trauma team leading was more common in clinicians at a MTS (odds ratio 3.19, 95%CI 1.00-10.20, P = 0.05). Conclusion: Exposure to major trauma is associated with time spent working in a MTS and exposure is associated with confidence. A mature inclusive trauma system must ensure clinicians across the system gain the experience or training to provide trauma care that will result in similar outcomes for patients regardless of initial presenting hospital.