Trauma presentations and podcast

Carl Shuker: Kia ora and welcome to Trauma Exchange, a series of conversations which explore the world of serious injury in New Zealand. My name is Carl Shuker and it's a privilege to host these discussions on behalf of the National Trauma Network and its partner organisation, Te Tahu Hauora Health Quality & Safety Commission.

The National Trauma Network was established in 2011. Its aim is to create a world-leading trauma care system in Aotearoa New Zealand by creating a culture of quality improvement and improved collaboration across regions. The network has influenced models of care that have saved lives and improved quality of life for survivors of major trauma.

In this episode, I'll be talking with Professor Ian Civil and Siobhan Isles about the Network's first decade and what to expect in the future.

Professor Civil is the National Clinical Director of the National Trauma Network, and Siobhan Isles was the National Programme Director for 12 years, from the Network's inception to 2023. Thank you both for joining me today.

Prof Ian Civil: Thank you, Carl.

Siobahn Isles: Thanks, Carl.

Carl: So Ian, what led to the establishment of the Network and why was a national network so important for New Zealand?

Prof Civil: Well, it's a quite a long story, Carl. Um, we've known about trauma systems, which is what a network is, being effective at reducing inequity and saving lives for a very long time. In fact, the early eighties in the US they had the very first evidence of that in the so-called two county study in California. But we've been quite slow to get on board with that principle in New Zealand. And right through the 90s, there was very little resonance in the health system at that stage with addressing the issues which were even more apparent there. There wasn't much interchange between regions and areas and doctors. And it became increasingly apparent that there was wide variation in care and outcomes for patients having suffering injuries, certainly in the... in the 90s and the first decade of this century.

And it got to the point where there was enough evidence around to present to, what was actually the precursor of the Commission, the Quality Improvement Committee back in 2010, the extent of the variation and the expected degree to which a network or a system could improve things.

And this was obviously using... not our own data because we didn't have our own registry, but rather data from other jurisdictions, particularly Victoria in Australia, which allowed us to present a case that really resonated with the decision makers at the time and the parliamentarians, and that we could do better both absolutely and relatively by making sure
that we had better systems and that there was more or less variation between different regions of the country.

Carl: So what would you say are some of the accomplishments you're most proud of since then?

Prof Civil: Well, I guess you can't do quality improvement work or improve anything without data. And while we had regional and hospital registries going back right to the mid-90s, there was no national registry. So it was not until we established a national registry, which was 2015, that we actually had information which we could start undertaking quality improvement work.

And registries are a bit of a labour of love, I'd have to say. They take a lot of maintenance, they take a lot of work, but the results, the outcomes that you can get from having an effective data repository are absolutely impressive. So that really has been one of the achievements which has underscored all of the progress of the Network.

The second achievement really stems from having data and working with the Commission using quality improvement methodology. And that is the way we have been able to address the issue of critical haemorrhage.

Now, when you suffer a major injury, if it's very severe, you may obviously die. And the usual causes are brain injury or, historically, have been bleeding to death. Now, when you get to hospital, we do have the tools in hospital to stop people dying, but still about 10 to 15 percent of patients who got to hospital died from haemorrhage. And we took the view that theoretically this should be preventable.

We took a road to zero type approach to critical haemorrhage and introduced a quality improvement programme which has, at this stage after only running for two or three years, reduced that mortality rate down from the... 10 to 15 percent down to 3 percent.

And I guess the third area where I'm really pleased to see how the overall work has produced outcomes has been reduction in mortality. And that's by people being aware of the data and applying the tools equitably across the country. So, it's really exciting that the overall mortality rate has dropped 10 percent, but it's even more exciting that the Maori mortality rate has dropped 25 percent. And that just shows how an approach applied evenly across the country can produce outcomes which really address inequity.

Carl: That's fantastic Ian. Siobhan, I'm interested from your perspective, what you would say is enable the network to deliver these accomplishments that Ian mentions, especially the latter two around haemorrhage and around inequity.

Siobhan: Well, I think the first thing is funding. The ACC funded us several years ago, and we're just at the end of a five-year business case at the moment. And that funding has enabled the development of the registry and the collection of data and the transformation of that data into information, which is really usable both by clinicians, but also by the sector and managers who are making decisions at every level of the trauma system, including pre-hospital and hospital and rehabilitation.

So, I think that funding supported by performance indicators. So we, Ian and I, have worked in a close partnership. It's been very results focused and we've spent considerable time and effort to measure our performance against the results, including mortality, but also including cost savings to ACC which is why they funded us in the first place.

I think one of the other reasons is really around the commissioning approach that ACC took to commission and give us the freedom and autonomy to drive a system and to drive that really strong clinical focus on what is, so that we could focus our time and effort on what is the most important and what would deliver the best value for money and get the results for patients, but also for their whanau and for the whole of the health system.

Carl: It's a real interagency collaboration. And Ian, I'm interested over the past five years, you've worked closely with Te Tahu Hauora, the Health Quality and Safety Commission. How has this collaboration influenced the network's work?

Prof Civil: Well, with the interaction with the Commission, it's really been fundamental to being able to deliver in whole areas of improvement, because without a really good quality improvement methodology, all you get is telling people what the expected results are and expecting them to get on and deliver. And in fact, it's really the barriers that exist already in the system, which are stopping people delivering on the current structure.

So, what we've been able to do with the Commission is work to develop appropriate quality improvement initiatives. Traumatic brain injuries, one, rehab’s, another and of course critical haemorrhage. We've got some others in the pipeline for chest injury and for severely injured limbs. And that methodology is, as has been proven in other areas, including safe surgery, which I worked on for many years, very effective at getting an outcome in the workplace.

Carl: Fantastic. Siobhan, I'm interested in what excites you about future opportunities in the trauma space.

Siobhan: Some of which I think Ian's alluded to there. Look, I think there's a really good foundation of work that's been established. And I think what should happen is for that foundation to continue and to continue to be built on. And I think particularly around the transformation of knowledge, of data into knowledge and using the scientific integrity that we've applied throughout all of this process and the research, building on the research from others.

So I think if I had to pick on two aspects that really excite me about the future, the first is around the opportunities to improve the move from patients from acute care to community rehabilitation. We know that there are a number of issues associated with that move. New Zealand, we're very incredibly fortunate that we've got a universal no fault system under ACC. What we do know though is that we have some real issues that while the transition from hospital to community might work really well for some patients, it does not work… we have not achieved that universal systematic approach for all patients.

And I think that is one of the key areas whereby particularly ACC and Te Whara Ora working in a slightly different way, we might be able to achieve some of those advantages for patients and the quality improvement expertise really underpins that.

And I think the second area is around research. Research is really the difference between a mediocre trauma system and a best performing trauma system. And really particularly because New Zealand’s population is not big enough; usually some of the collaborations with countries such as Norway and Australia that we can compare quite closely with, those research collaborations can be enormously important to building up the wealth of knowledge in New Zealand.

Carl: Ian, people may not know that the network actually works beyond just the health and disability system. Some of the work you've done with New Zealand Police, for example, to understand the impacts of prescription drugs on road traffic accidents and major trauma.

Prof Civil: Well, trauma is predominant in certain populations, and we're very keen, and we have been very keen, to work with those agencies that have a role in both injury prevention and ongoing management of patients or people that are exposed to that environment.

So I guess at the top of our list would be Waka Kotahi, which road traffic-related incidents being represented with just over 50 percent of all major trauma patients. They have a very major role in potentially supporting the work we're doing in the clinical space, but also us supporting them in the environmental space to reduce the likelihood of patients suffering injury or reduce the severity.

Similarly, many of our patients who have major injury have had exposure to or are exposed to drugs. And so, working with police to understand where drugs are prevalent and what we can do to reduce the impact on people, that they are less likely to become a major trauma patient, is a big feature of our work.

There are a number of other areas, particularly in remote environments and with other population groups where trauma is more prevalent, and we've been keen to work with any agencies that have particular knowledge and activity in those areas.

Carl: Siobhan, is the Trauma Network's work exclusively focused on hospital care?

Siobhan: No, Carl, the Trauma Network focuses on the journey of care from the point of injury through pre-hospital care, particularly with the ambulance services, hospital care and rehabilitation. And our early focus was on that pre-hospital care and early period of time in the first hospital. And we changed that, we spent a lot of time to implement triage criteria so that patients would be taken to the best hospital, or the most appropriate hospital from the point of injury. And we've had fantastic collaboration with the ambulance services, as well as with all of the hospitals.

So, we encompass that whole-of-system approach and take that whole of system approach in our work.

Carl: Ian, do you have any perspectives on that question?

Prof Civil: I think the early achievements with the pre-hospital care providers were really crucial to getting better outcomes. We know that patients are more likely to suffer complications and more likely to die if they have to be transferred between two hospitals. And when we started this work, about 70 percent of our patients were getting hospital that could provide all the care that they needed and about 30 percent needed to be transferred.

At this stage we've got up into the low 80 percents of patients who now go to a hospital where they can get all of their injury treatment provided and we're hopeful to get even more. What will be the limit we don't know but we certainly are aiming to get as many patients into the right hospital and the first on the first journey. and working with the ambulance services is the best way to do that.

Carl: Siobhan, any last thoughts?

Siobhan: Yeah, look, I think the impact of the network on people who are seriously injured and their whanau is really important. And while the general public might not be necessarily aware of it, just a lot of that system approach and that movement of the system so that patient, if you are injured, you're more likely to be taken to a hospital that deals with complex injured patients more often, plus the comprehensive coordination of care inside that hospital is really important.

And I think that some of these initiatives have an incredible impact, positive impact on patients. And I think the buildup of capacity and capability across the trauma system is really important as well.

Carl: Ian, any last thoughts from you?

Prof Civil: No, I'm looking forward to the network being able to continue its work and to be able to deliver future gains and reduce both the mortality from patients who are unfortunate enough to suffer major injury, but also improve the quality of life.

One of the things that I'm very hopeful we'll be able to achieve is more consistent measurement of patients' outcomes in the months and years after discharge. Although a small minority of people die after injury, most survive, and they are particularly interested and we're interested in what their outcomes are.

We did some work on patient reported outcome measures and hopefully we'll be able to do this on all patients suffering major trauma in the future.

Carl: Well, it's been fantastic to hear about this work, about what the National Trauma Network has come from over the past decade and where you're headed.

It's clear from what you've shared with us that though you've accomplished a lot, the Network has still got a lot of opportunity ahead and I'm sure you'll continue to influence improvement in trauma care for health care providers and to improve outcomes for those experience major trauma and their whanau.

So, thanks for your time today Ian and Siobhan, it was great to speak with you both.

And if you want to learn more about the National Trauma Network and their work, feel free to explore the National Trauma Network website. That's at www dot majortrauma dot nz.

Thanks again for joining us.

Ma te wa.

Carl Shuker: Kia ora and welcome to Trauma Exchange, a series of conversations which explore the world of serious injury in New Zealand. My name is Carl Shuker and it's a privilege to host these discussions on behalf of the National Trauma Network and its partner organisation, Te Tāhū Hauora Health Quality & Safety Commission.

Contemporary trauma systems are not just about providing state of the art care that provides value for money, but also about designing models of care and treatment using a combination of evidence from both quality improvement methods and from scientific research.

I'm Carl Shuker and in this episode, I'll be talking to Professor Belinda Gabbe about her world leading research on serious injury. Belinda is the head of the pre-hospital emergency and trauma research unit at Monash University in Victoria and is research lead for the National Trauma Network in New Zealand.

Kia ora Belinda, thank you for joining us from Melbourne.

Professor Belinda Gabbe: Thanks so much for having me.

Carl: So, Belinda can you tell us a little bit about what emergency trauma research involves?

Prof Gabbe: So, it's a pretty diverse area really. It's really, as you've mentioned, talking about how we deliver trauma care, but it's really about understanding who our trauma patients are. So the epidemiology, a word that became very much in people's minds during the pandemic. But understanding who our patients are, how they're being injured, why they're being injured, but also understanding the care and the outcomes… the care that they receive and the outcomes that they receive. And also, the research focuses on actually improving that care and outcome so that people can get the best possible outcomes from their injuries.

Carl: That's awesome. And you've also written papers which show the benefit of an organised trauma system on patient outcomes. Can you tell us a little bit about that work?

Prof Gabbe: Yes, of course. In Victoria, in Australia, in the early 2000s, we rolled out a new trauma system. And that trauma system was really about bypassing smaller hospitals for the very seriously injured and actually transporting them, preferentially transporting them, to these one-stop shops, these major trauma services. And this is a model that's being used around the world. But most of the evidence had actually come from North America. And most of the evidence had actually focused only on the survival of patients and not necessarily on the quality of the survival of patients as well.

So, in a series of papers and following the introduction of our new trauma system, we were able to actually show that the introduction of the trauma system meant that more patients were receiving their care at these specialist trauma centres, and that had a significant survival benefit.

But we were also able to show, because we follow up our patients after their injuries to see how well they recover, we were also able to show that care at those major trauma centres actually resulted in better functional outcomes for patients as well. So, they're not only more likely to survive, but they were actually more likely to have a better functional outcome.

And then on the other side of that, we also looked at what the impact had been on the costs of trauma. And here we're talking about converting disability adjusted life years or measures of mortality and morbidity into a cost amount. And we were able to show that the introduction of the trauma system was actually associated with a significant cost benefit, in that people were more likely to survive and therefore the costs of those deaths was lower, but also because patients were having better functional outcomes as well.

So, we could see that we were, that translated into a lower burden or a lower cost to society as well.

Carl: That's fantastic. And as a result of that research, were there practical changes, real world changes in systems in Australia and New Zealand that followed on?

Prof Gabbe: Yeah, I think it really has. I mean, as I said, it was the first real evidence that had come from anywhere other than North America. And as you know, as many will know, the health care system in North America is actually profoundly different to Australia and to New Zealand and to other places in the world.

And the data that we generated and the research that we generated was actually used to implement trauma systems in similar trauma systems in the United Kingdom, particularly in England… and also in England and Wales, I should say, but also in New Zealand as well. So really it was what it was saying is that these inclusive trauma systems, these trauma systems that preferentially bring patients through to these specialist centres is actually should be the standard of care and should be used around the world. And we've been seeing them rolled out pretty much across the world now.

Carl: Belinda, you mentioned functional outcomes. What does functional outcomes mean and how would you measure those?

Prof Gabbe: It’s broad term and there are multiple ways that functional outcomes can be measured. But here we're talking about the things that are pretty important to people, which are things like whether they've been able to go back to work, how they're getting around the community, can they do activities of daily life like washing themselves, cooking their food, going and doing their shopping, interacting with friends, doing all of their recreational and sort of social activities. So functional outcome has that very wide perspective.

In the studies that we've done, we've often used something called an extended Glasgow outcome scale, which really is a measure of the degree in which the issues related to injury are actually impacting on their outcomes. And so we can get an actual sort of score that tells us whether people are living independently, whether they're needing services or supports, or whether they've actually made a full recovery and they're actually having absolutely no issues related to their injury.

But there are other measures out there and we do other measures of health-related quality of life and those types of things as well, but it's a pretty broad term and there are lots of ways to measure it.

Carl: So, this is a slightly odd question, but it's certainly true in quality improvement that sometimes we learn more from what has failed than what works. And I'd be interested in your reflections on any research that hasn't worked out and that has led you into, perhaps, new and more fruitful places.

Prof Gabbe: Yeah, in the last probably 20 years, a lot of my work, I'm a physiotherapist by background. So, my interest is really how well people recover from their injuries, so I'm very interested in the allied health care we give to our patients. I'm very interested in the follow-up that we give to our patients as well to really maximise their chances of a good recovery.

And we'd been doing quite a lot of research that had been saying that when people leave the major trauma centres or major trauma services, it's like falling off a cliff. There's this disconnect between the care that they receive in the trauma centre and then what happens out in the community. And so, we used that information to develop a new role at the trauma centres called major trauma recovery coordinators.

And we undertook a study where we implemented them at a big trauma centre, over a period of time, to see whether these major trauma recovery coordinators who are really responsible for following up the patients once they've left, troubleshooting any issues that they were having, making sure all their services were in place before they left the hospital, organising their outpatient appointments to be really streamlined, would actually improve patient outcomes over time.

And what we found was that, even though we'd really prepared well for the study, we actually probably didn't do it in the best possible way. And we actually didn't really find a benefit from those roles. So what we actually found was that the number of trauma patients that were coming into the hospital was going up far too quickly. And there weren't enough of these major trauma recovery coordinators to actually see everybody. So, what they were having to do was actually see the patients that they felt would have the biggest need. And obviously they were the people that would be at more risk of a poorer outcome.

So, because we couldn't actually have major trauma recovery coordinators actually interacting with every patient, we probably missed an opportunity to see what the real impact would be. But what we did get was a lot of information back from patients to say that they really valued the role and the aspects of the role that they really valued and their experiences.

And what we were able to do was actually turn that into a new approach, which was really more around redesigning allied health care in the major trauma centre to be multidisciplinary, seven days a week and really intensive to try and give people the best start to their rehabilitation and the best opportunity to return home quickly and to recover quickly.

And we completed that work and actually published it recently and we were able to show that new allied health model of care was actually… actually improved patient outcomes, it shortened their length of stay and it was shown to be extremely cost effective and has now become the standard of care. So out of failure came success. And what's really important about that is it's success for the patients. So we were really happy about that.

But that first one was really disappointing, but you've got to take the information that you get and turn it into whatever you can really.

And all research is an opportunity to learn.

Carl: Congratulations, that's amazing. It sort of speaks to that idea, I think it was Solberg wrote about differences between evidence for research and evidence for quality improvement, having slightly different approaches sometimes.

Prof Gabbe: Yeah, that's true. And every question that you ask requires a slightly different approach or to tackle it in a different way, or you set out to do something, but you learn you've got to be adaptive. You've got to have that sort of flexibility to actually adapt to what you're doing along the way when more information actually comes in.

So, it's a constant learning curve, really. You never stop learning in trauma research, that's for sure.

Carl: So, this sort of brings me to my next question. Perhaps from the outside, that research is often seen as the domain of academics, and you've talked about your background. But trauma clinicians can get involved in research too. And can you talk to us about how they can do that?

Prof Gabbe: Trauma clinicians and the input into research is absolutely fundamental. It's critical to all the work that I do. We would never undertake a project in trauma research without involvement from clinicians, and that level of involvement can vary substantially.

So, it could be providing advice, or they'll often bring a question to us that they've got from their clinical practice that they would like to answer.

Clinicians can get involved in leading projects and a lot of the researchers will provide methodological support, so our job is to help them design the research and make sure that it's scientifically sound but ultimately, it'll be the clinicians that are actually implementing that research.

And then there's all the way through to doing, you know, honours degrees, master's degrees, PhDs and the like.

And we've got a lot of clinicians that are running full programmes of research themselves from within their health care services. And our job really is to provide the data and the support to that as well.

And often the pieces that they're missing can be around the study design and really making sure that it's really, really sound. But also, it's really in providing the data that will actually help them get the project off the ground and also providing things like biostatistical support, which is a specialty area of all of its own.

But from our point of view, the involvement of clinicians is absolutely critical. It's, they have an incredible understanding of what's going on out there. They're interacting with patients all the time. They're interacting with the trauma system all the time. And they also help to understand, you know, they really help us to understand what these findings mean and how they could actually be used to implement change for the better.

Carl: That's wonderful. Can you talk to us maybe a little bit about your hopes for the future or your plans, ambitions for the future of the Trauma Network and the research you're doing?

Prof Gabbe: The Trauma Network, I mean, New Zealand is really coming along in leaps and bounds. It's been an outstanding investment from New Zealand into improved health care and improved trauma care for patients.

From my perspective, as I said, I always really come from that side, which is really looking at patient recovery and patient outcomes. And I think that the case studies and the collectives that have been done in rehabilitation have really gathered an enormous amount of information and provided some real guidance for New Zealand about rehabilitation for trauma patients.

I think the data linkage capability that New Zealand actually has is world class and there's a lot to be gained from the linkage of health data and ACC data and social data as well to understand how well patients in New Zealand actually recover from injury and where the touch points along their recovery are that we could intervene to actually improve things even further.

And also the collection of the long-term outcomes, it would be really wonderful to see that continuing because most of our patients actually survive their injuries and, as I said, the quality of survival for them is paramount and it's very hard to have evidence to improve things if you don't have the data behind you to actually do that.

So, I see there are you know an enormous number of initiatives and possibilities in the New Zealand Trauma Network to actually improve outcomes for patients.

Carl: Well Belinda, it's been a pleasure to talk with you today and thank you for joining us.

If you'd like to learn more about the trauma research programme in New Zealand, Australia or across the world, feel free to explore the National Trauma Network and Tāhū Hauora Health Quality & Safety Commission websites, www.majortrauma.nz or www.hqsc.govt.nz.

Thank you to Belinda Gabbe for joining us today and thank you for joining us.

Mā te wā.

Carl Shuker: Kia ora and welcome to Trauma Exchange, a series of conversations which explore the world of serious injury in New Zealand. My name is Carl Shuker and it's a privilege to host these discussions on behalf of the National Trauma Network and its partner organisation, Te Tāhū Hauora Health Quality & Safety Commission.

Māori experience major trauma more often than non-Māori, across all age and gender groups younger than 65 years. And once out of hospital, Māori are also less likely to access rehabilitation services. And when these services are accessed, Māori spend much less time there receiving the care they need.

In this episode I talk with Sharon Pihema to discuss the findings and recommendations from a 2022 report describing the experiences of major trauma care and rehabilitation for Māori. We'll also be talking about some really practical tips for health care providers to improve the care and outcomes for their Māori patients.

Sharon is currently a consultant and Māori health advisor to Asthma New Zealand and is studying digital media with a specific focus on public health.

Tēnā koe, Sharon. Thanks for being here today.

Sharon Pihema: Tēnā koe. Thank you for having me.

Carl: Sharon, can you give us a bit of an overview of the report? How did you identify that access to rehabilitation for Māori was an area of concern?

Sharon: We knew that from a lot of the research that Māori were experiencing much more major trauma compared to non-Māori. We knew that when we looked at gender, tāne Māori were experiencing much higher major trauma rates than non-Māori males, and similarly for wāhine Māori as well.

When we also looked at disability outcomes, we could see that Māori were experiencing much higher rates of disability from all different types of injury. And then as they moved into services such as ACC, we could see that Māori were having much lower rates of access, taking longer to access services and having fewer interactions with the support services that they needed.

So, all of that evidence and data and information showed us that we needed to get a more detailed understanding about the whānau journey with major trauma rehabilitation. And the way to do that was to go out and kōrero and meet with whānau that had gone through this to get an understanding of how their experience was, what parts of the journey worked well, what didn't, and where we needed to make improvements.

Carl: That's fantastic. So, we hear this term culturally responsive care. Can you tell us about how you feel trauma services could provide more culturally responsive care and why that's important?

Sharon: Culturally responsive care was really important and something that came through a lot of the interviews that we had with whānau. Whānau who had a really challenging, difficult experience with their recovery and rehabilitation, there were examples in there that we could see where cultural competency played a really major part in that.

And one of the ones that stood out the most for us was around whakawhanaungatanga, and clinicians taking the time to get to know the person, to build that relationship, to find that connection, to engage with the person and their whānau. That was a really key part that when it was present in a lot of the journeys that we spoke about, people had a much more positive rehabilitation experience.

When something like whanaungatanga wasn't there and was absent, it was much harder for whānau to engage in their journey, to engage with the people that were looking after them. and it made the whole experience much more difficult for them to cope with.

Carl: And does that mean we lose Māori to rehabilitation services when that doesn't happen?

Sharon: I think that it definitely has an impact. I think that if you are a clinician or a support worker or anyone that's working with whānau in this space, that ensuring that you are practicing whanaungatanga, that you are listening to the person and including them and their whānau… all of those aspects of whanaungatanga and manaakitanga really make a difference. And when you're in a journey like trauma rehabilitation for weeks, months, years and you are coming across dozens of different people, everybody has a role to play in ensuring that whānau, the person that's going through recovery, is feeling supported, feeling included.

And that relationship that you get, and that mutual respect is critical to the outcome that people have with their rehabilitation.

Carl: Sharon, what does manaakitanga look like and feel like in a trauma space?

Sharon: So manaakitanga is around looking after others and taking care of others and being kind and showing kindness and respect. And clinicians can play a key role in practicing manaakitanga when they are interacting with us as whānau.

So right from the outset with those first conversations, when we're first meeting you… take the time to introduce yourself, share a little bit about where you're from, about your whānau, about your background, and we'll do the same. And by doing that, we create that connection and that common ground for us to build our relationship together.

And then moving forward, we know that we can trust you. We know that you're going to include us in the discussions and in the decisions, and we have that respect with each other that's really important when we're in such a long journey like major trauma rehabilitation.

Manaakitanga can look like lots of things. So, it can be not just learning how to say our names correctly and how to pronounce te reo Māori correctly, because that should happen regardless. But also looking at things like karakia. For a lot of whānau, that's really important, and they lean on that when they're in such challenging times like rehabilitation and spending time in hospital. So, if that's something that's important for whānau, allow that to happen. You may want to participate in that, learn more about it. That's fantastic.

Learn about what's important to us as whānau, and we'll let you know. If something like what our mokopuna are up to, or what school they go to, or if it's kapa haka season, or if there's really significant things happening in our lives, an example being like Matariki, take the time to learn about that. Ask us questions, have those conversations. All of that really helps to build that relationship and that connection with us moving forward.

Carl: That's fantastic, Sharon. So, can you tell us a little bit more about how you got that information, how you engaged with people, and what that process was like?

Sharon: We took a very whanau-led process throughout this whole project. So, once we had identified whānau that were eligible to be included in our project, we contacted them and let them decide how they wanted to share their kōrero with us. So, whether that was having a conversation kānohi ki te kānohi face to face, whether it was over the phone, whether it was on Zoom, we left it up to whānau to decide what would work best for them.

We also let them decide who they wanted to have in the interview with them, whether they wanted to be by themselves, whether they wanted other whānau members there, whether they wanted a support worker or a friend. We let them decide that as well.

And then… same with the discussion and the questions that we were going to ask. We didn't go in there with a list of questions. We left it very much open for whānau to decide what parts of their journey they wanted to share with us, how much information they wanted to share with us. And when we took that approach, the kōrero that they shared with us just had a natural flow about it. And we were able to get some really good kōrero, some really good whakaaro, some feedback that helped us put this report together to come up with these recommendations and findings.

Carl: So, what can we do in the health system to make experiences of care better for Māori? I mean, you talk about in the study these processes that sound like they're some of the similar processes that you want to see in the health system itself.

Sharon: When we interviewed whānau, there were some key themes that came through really strongly. One was whanaungatanga and how important that is. There were other aspects such as needing to consider the mental health impacts of trauma, of trauma rehabilitation on the person and their whānau. We had a number of whānau talking about just how hard that mental health challenge was for them. In terms of they knew they had really serious injuries, but the impact on their mental health was what they struggled with the most. So we need to make sure that we have that flagged and as a priority throughout the whole journey, not just while they're in hospital, but at other parts throughout their journey – post discharge two, three years down the track, they still need to be able to access that support for their mental health.

We know that we need better coordination of support services. The whānau that we interviewed, a lot of them, there was no central one point of coordination. So, it was very fragmented. They were very confused about who was doing what, who they were meant to approach for help with different things. We need better coordination of that.

We need better support and recognition for the whole whānau unit, because they are the key support for that person as they're going through rehabilitation. So often whānau are having to carry a lot of the burden in terms of finances, in terms of... other whānau members, other children that might be needing to be looked after. We need to support whānau so that they can support their loved one going through rehabilitation.

We also need to make sure that we're looking after our rangatahi that are going through major trauma rehabilitation as well, because they have unique needs that are different from us as adults, and having to go through something as significant as major trauma can be really struggling for this age group. And by rangatahi, I mean kind of the 24 years and younger. We need to have appropriate support and services to help them. And we need the workforce to be trained up so that they can effectively work and engage with our rangatahi.

Carl: Look, your report was published in April 2022. What's been done and what have you seen since then to encourage more culturally appropriate care?

Sharon: Since the report was released, there has been work happening at a regional level with different trauma networks. So, using this report to provide that starting point for reflection on what each network is doing in their locations in terms of things like whanaungatanga, mental health support, supporting rangatahi. That activity is happening at a regional level.

There's also examples such as with ABI Rehabilitation, where they have used the report to inform the development of their Māori health development plan as an organisation. And then they've gone so far as to set up a mātauranga Māori advisory group for the organisation. So, it's a collective group of people with different areas of expertise and experience within mātauranga Māori to help... provide that guidance and that support and that insight to ABI, so that they can then filter down that development plan throughout the different levels of their organisation.

So, there are some really promising areas of work happening in this space which is great to see.

Carl: That is great to see. Sharon, any last thoughts that you wanted to share with us about your deep knowledge of this space?

Sharon: This was a really... humbling experience to be a part of, to be able to go out and talk with and meet with 21 different whānau about their experience with major trauma. It really highlighted how much of an impact something like this has on the person and their whole whānau.

A lot of these whānau were just doing, you know, some of them were doing everyday activities, some of them were at work when their accidents happened, some of them were just travelling home after a whānau event and then these major trauma events happen, and it really changes their trajectory.

And so, I guess it's about us as a workforce coming together, working together, creating this cohesive collaborative experience for whānau so that they can get closer to where they were wanting to be before their accident happened.

It's really important because a lot of whānau hadn't had a positive experience with their rehabilitation and you know one year, two years post injury when I came to speak with them, they were still really struggling by themselves. And when you hear their journeys, you can see exact points where there was an opportunity to engage with them, to change that path that they're now on.

And I think it's really important that the workforce all come together to awhi and support our whānau through this.

Carl: Kia ora Sharon, it's been a pleasure to hear your kōrero today. Thank you for your time.

Māori who experience major trauma have a right to better care and to equitable outcomes. Offering culturally responsive care is a step in the right direction to positively impact experiences and outcomes of care.

If you'd like to read more about some of the things Sharon's talked about today, you can find information about the incidence of major trauma among Māori in the National Trauma Registry Annual Reports on the National Trauma Network website. Information about the longer-term outcomes from injury, including for Māori, can be found on the University of Otago website by searching for the prospective outcomes of injury study.

If you'd like to learn more about the National Trauma Network or read Sharon's report in full you can find more information at the National Trauma Network and Te Tāhū Hauora Health Quality & Safety Commission websites. That's www.majortrauma.nz or www.hqsc.govt.nz.

Thanks again for joining us.

Mā te wā.

Carl Shuker: Music Kia ora and welcome to Trauma Exchange, a series of conversations which explore the world of serious injury in New Zealand. My name is Carl Shuker and it's a privilege to host these discussions on behalf of the National Trauma Network and its partner organisation, Te Tāhū Hauora Health Quality & Safety Commission.

Physical injury is the leading cause of death for people in Aotearoa aged between 1 and 39 years. For those who survive, many require extensive rehabilitation to support recovery from complex injuries. We know that the sooner rehabilitation starts, the better the outcomes for the patient and they can return to normal life sooner.

So, today I'm speaking to occupational therapist, Jonathan Armstrong, about his role in recent quality improvement projects for trauma patients in the hospital and for those transitioning back into the community. We'll be talking about how these projects have improved the rehabilitation journeys of people with serious injury in Tāmaki Makaurau and across Aotearoa, New Zealand.

Jonathan is an experienced occupational therapist at ABI Rehabilitation and was previously the Director of Allied Health at Te Whatu Ora Counties Manukau.

He worked on projects for both Counties Manukau and ABI Rehab and Active Plus Rehab and he's now an advisor for the serious traumatic brain injury national collaborative run by Te Tāhū Hauora.

Jonathan, you've been involved in a few quality improvement projects with the network and Te Tāhū Hauora recently, with a focus on how traumatic brain injury is managed in hospital and community settings. So, can you tell us a little bit about your first project, which looked at the accuracy of assessment and screening of inpatients with traumatic brain injury?

Jonathan Armstrong: Sure, so people who are admitted to hospital with a suspected traumatic brain injury are usually screened a number of ways, including using radiology like a CT scan of their brain, using standardised cognitive measures to assess their thinking abilities and using symptom screens that check if a person is experiencing any signs of brain injury such as headaches or sensitivity to light or dizziness.

All those components of assessment have to be consistent and accurate in order to correctly diagnose the severity of the brain injury and help to make clinical decisions about how it's managed.

So at Te Whatu Ora Counties Manukau, we recognise that there was the potential for error in screening people with traumatic brain injury, particularly if that injury was relatively mild and didn't appear apparent in the usual clinical interviews, or if the person was a major multi trauma injury where attention had to be focused on other significant injuries, like orthopaedic or spinal or abdominal.

So, we particularly wanted to focus on the assessment of cognitive status that's undertaken to establish if a person is in a state of post-traumatic amnesia. And that's an important measure as it tells us how severe somebody's injury is and also tells us what kind of support or ongoing rehab they're likely to need.

Carl: And what can you tell us about how to complete these assessments and what you found?

Jonathan: The assessment that we use is called a Westmead Post Traumatic Amnesia Scale or PTA scale and has to be repeated daily to establish if continuous memory has returned. So, we test to see if the person can do things like recall where they are, what's happened to them and simple information that they've been asked to remember from the day before like names and faces. And all those are essential skills to be able to cope in everyday life, and they're all also typical signs of post-traumatic amnesia.

So, when we conducted a baseline of assessments over a period of four months, what we found was that there were some common errors occurring in a particular section of that assessment, approximately 50 percent of the time. And that's due to the assessment having to be repeated on a daily basis.

Sometimes over a number of days and sometimes, as the person moves through the hospital to different wards, the assessment has to be conducted by different people. So, we wanted to improve that so that we could be certain that injured people were being assessed accurately and thereby receiving the right kind of cognitive management while in the hospital and also being referred on to the right support services and rehab when they were discharged.

Carl: And what sorts of changes did you make based on those findings?

Jonathan: So there were a number of rehab improvement activities we put in place. We created online e-learning tools. We did face-to-face education sessions, created ward-based champions who were the go-to people to assist with any uncertainties. And we created more accessible resources for the assessment, and all those aimed to improve the accuracy of the assessment.

And auditing is ongoing to ensure that the improvements continue and they make positive change to the identification and the management of people when they're in post-traumatic amnesia.

Carl: Jonathan, that's fantastic work. And I understand that work has had some impact at a national level. Can you tell us about your role in achieving national consistency in that screening for post-traumatic amnesia?

Jonathan: So, the National Trauma Network, while we were working with them on this original project, they recognised that the issues that we were addressing through our project were wider than just Te Whatu Ora Counties Manukau. And this work could have a positive impact across other districts.

So, two of us from the original project at Counties joined the Health Quality & Safety Commission and the National Trauma Network as advisors to help with what was called the serious traumatic brain injury collaborative. So other Te Whatu Ora districts could kind of get knowledge from what we'd achieved and try and put some of those quality improvement projects into their own districts and see how they worked.

So, they used some of our quality improvement tools that were created in the original project, such as the audit tool and the e-learning, and just got a baseline of where their issues might lie in terms of consistent and accurate screening, and then looked at ways to address any challenges that they had in their particular services.

Carl: How many teams were participating in that collaborative, and did they have any success?

Jonathan So, there were two phases to that serious TBI collaborative. The first involved five teams and they were Northland, Bay of Plenty, Hawke's Bay, Taranaki and Southland. And then there was a second phase that involved four other teams: Auckland, MidCentral, Nelson and Marlborough and Canterbury.

And so, each district reviewed their own processes and assessments and each found that they had slightly different areas that needed to be addressed. For some, it was around the initial identification of people with a suspected brain injury. For others, it was about undertaking assessment accurately in a particular area of their hospital. For others, it was about providing the right management and education to people and their whānau once the injury had been identified and was in the process of being assessed.

What was great about all the collaboratives was that everybody's efforts were all, from the different districts, were all shared. Everybody found different solutions to their own challenges, and then those were shared with others so that we're all learning from one another and we're all borrowing the solutions that had been proven to work elsewhere.

Carl: Classic QI collaborative stuff, that's awesome. So, Jonathan, can you talk to us about potential consequences for patients if post-traumatic amnesia isn't identified?

Jonathan: So, people can leave the hospital unaware of their cognitive difficulties and when they return home or try to return to their usual roles like looking after their children or going back to work or resuming study, they begin to struggle and have a limited understanding of why they're struggling or what can be done to help.

They can have issues with a whole range of thinking or cognitive skills. They may struggle with concentrating; it might take them longer to think things through. They can't remember information that they've been given relatively recently, and it therefore becomes much harder to make plans or make decisions.

Those kinds of difficulties are often invisible to people. They're not obvious like a broken leg or a weak arm. So, they're really difficult for the person with the brain injury to understand, but also for the people around them like their whānau to understand. So, without the right support in place, people can become really frustrated and often very confused about what's happening to them.

When those issues are identified early on with the right screening, then the right support, such as inpatient or community rehab, can be offered so that there are professionals providing advice and strategies to manage those kinds of difficulties. And the person can begin to return to daily life with an understanding of what those difficulties are, why they're happening, and also have some tools to manage those cognitive changes.

The other important thing about the assessment of post-traumatic amnesia is the duration of somebody's post-traumatic amnesia does define the severity of their brain injury. And the severity of your brain injury also often defines the services that you're eligible for when you are discharged from hospital. So, there's kind of a number of reasons why getting the screening for post-traumatic amnesia is really important.

Carl: So you touched there on some of the implications for the wider whānau of patients. Can you talk more about the implications of these improvements for families and whānau of patients affected by these kinds of injuries?

Jonathan: Yeah, so when we are referring to community rehabilitation teams to support the person with brain injury, it's very important to not just be supporting the person with the injury, but also the team of people around them. And that includes obviously their whānau.

And, you know, we know that as brain injury rehab specialists, we're only a very short part of this person's recovery journey. And it's the whānau that needs to support those people in the long term. So, actually upskilling the whānau and sharing education and resources with them is so important because they're the people that are going to be supporting this individual long term.

Carl: Of course family and whānau being involved in the rehabilitation process can be such a huge part of a patient's recovery so that's great to hear.

Another important project that you were involved in was a collaboration between ABI Rehab, Active Plus Rehab, ACC and Te Whatu Ora Counties Manukau. Can you tell us a little bit about what that project hoped to achieve?

Jonathan: Yeah. So that project aimed to streamline the referral processes from the hospital to the community TBI rehabilitation services, aiming to get major trauma patients and their whānau the right community-based rehab to meet their needs at the right time.

Carl: And what changes were made to that existing process?

Jonathan: So, prior to that piece of work being done, Middlemore Hospital wards and the ED all had different ways of making referrals to community rehab providers and were all using different referral forms. Sometimes those templates didn't accurately identify the injured person's needs and injured people were not getting picked up by rehab providers for weeks after their discharge from hospital. And in the baseline data, it was found that the average time from discharge to entry into a TBI rehab community service was just over 40 working days.

So, we worked across the organisations: ABI Rehabilitation, Active Plus, AUT, ACC and Te Whatu Ora Counties Manukau to map out the process of referral and look at where the difficulties in the bottlenecks arose and then addressed each one of those individually.

So, one issue that became evident was the multiple forms that people could use to refer to community rehab services and each had their different level of detail. So, we worked with the referring and the receiving teams on creating one form that was going to meet everybody's needs in terms of the details provided. One that was quick for the hospital team to complete but was also comprehensive enough for the community teams to start their assessment. And we also worked on a feedback loop so that the people who were referring in the hospital knew that the referral had been received and knew that it had been accepted.

Working with ACC, we were also able to look at bottlenecks in the approval process and remove those to speed the process up. So, ACC provided pre-approval for people being discharged from Middlemore Hospital and only got involved after the person started their rehab with ABI or Active Plus. And those changes resulted in an average time from discharged community follow-up becoming just over two working days as opposed to the 40 plus that had been originally.

Carl: That's extraordinary. So, I mean, my follow-up question was, what would it feel like to patients outside needing community rehabilitation, but obviously it feels 38 days better.

Jonathan: Yeah, people are now receiving their community support a lot earlier, and therefore, they're hopefully not struggling at home or trying to return to work or school with a brain injury and all the related symptoms that they're not able to manage.

Our community teams have also found that this earlier intervention has reduced injured people's needs to be referring to doctor Google, and becoming distressed with their symptoms as they have brain injury experts to talk to and know what to expect.

So, the providers like ABI Rehab and Active Plus are now able to provide early intervention and support with clinicians that have expertise in neurological rehabilitation and can address the multiple symptoms that people are experiencing, whether those are balance issues, visual issues, cognitive or fatigue issues.

And hopefully injured people will feel like they've not been left in the dark to struggle through those difficulties alone and they have expert clinicians who can walk alongside them early on as they're going through their recovery, and offering education and intervention and support to address the issues as they arise.

Carl: It's an extraordinary improvement, Jonathan. Is it an initiative that only patients in Tamaki Makaurau will benefit from at this point?

Jonathan: So the pilot was so successful that ACC took the findings and scaled up many aspects of that project. And they started rolling that out across all hospitals in August of last year, which has meant that these improvements in access to community rehab can be achieved across Aotearoa.

Carl: That's so fantastic. You've been at the centre of this. Do you have any other tips for other teams around the country who want to improve their local services?

Jonathan: Yeah, so I would say that I have two main tips for people who want to take on quality improvement projects like these ones I've been describing.

My first tip would be that people really need to take their time to study the problem that they're trying to address. On the surface of things, it may seem like an issue with a process or a system or assessment maybe due to a particular area. And when you delve deeper, you find that actually the problem lies elsewhere, most likely further upstream from the point that you originally thought it originated from. It's worth taking extra time to really examine the problem so that whatever solution you're putting in place actually addresses the underlying issue.

And my second tip would be to get a group of people together that are really passionate about solving the problem you're trying to address. The great thing about the two projects that I've described here was that we had a dream team of people who really wanted to do their best to make improvements. We all had expertise in different areas, but we all had a common goal of improving access to brain injury services and outcomes for people who'd experienced a brain injury.

Carl: Well, thank you so much for speaking with me today, Jonathan. It's extraordinary work. Yeah, I keep thinking in my head, 40 working days down to two working days. It's just an extraordinary improvement.

Congratulations, and we should also acknowledge the hard work that went into this project from your other team members and collaborators: ABI Rehabilitation, Active Plus, Te Whatu Ora Counties Manukau, ACC and the Auckland University of Technology.

Thanks for joining our conversation with Jonathan Armstrong today. It's great hearing about how approval of referral information and removing pre-approvals for patients to receive concussion services dramatically reduce the time patients wait for care. Now the screening process for post-traumatic amnesia is being improved across Aotearoa.

Thank you for joining us.

If you'd like more information about this mahi or would like to learn about other projects completed during the trauma rehabilitation collaborative, check out the National Trauma Network and Tāhū Hauora Health Quality & Safety Commission websites. That's at www.majortrauma.nz or at www.hqsc.govt.nz.

Thanks again for joining us.

Mā te wā.

Carl Shuker: Kia ora and welcome to Trauma Exchange, a series of conversations which explore the world of serious injury in New Zealand. My name is Carl Shuker and it's a privilege to host these discussions on behalf of the National Trauma Network and its partner organisation, Te Tāhū Hauora Health Quality & Safety Commission.

Physical injury is the leading cause of death for people in Aotearoa aged between 1 and 39 years, and blood loss, or haemorrhage, is the most common cause of death in the first 12 hours after a person is injured, even once they've reached hospital.

Today, Doctor Kerry Gunn joins me to talk about a quality improvement project to try and reduce avoidable deaths from blood loss after trauma. We'll be talking about some of the things that made this work a success.

Kerry is an anaesthetist with a special interest in coagulopathy and massive haemorrhage management. He was the clinical lead for the critical haemorrhage project, run by the National Trauma Network in partnership with Te Tāhū Hauora Health Quality & Safety Commission.

Kia ora and welcome, Kerry, thank you for taking the time to share this mahi.

Dr Kerry Gunn: Thank you. Thank you for having me.

Carl: So, Kerry, what was it about critical haemorrhage that drove you to start an improvement project on it?

Dr Gunn: Well, as you alluded to in your introduction, it is a significant problem for us as clinicians in New Zealand in dealing with major haemorrhage with trauma.

The numbers that you described show that it is a major problem, it's a difficult to manage problem, and these patients go on to die early in their hospital course of haemorrhage. So, as an improvement project, it was immediately obvious to us that we could reduce the amount or the burden of death and trauma through an improvement programme.

The problem was that A, the numbers are relatively small across the whole country. So, the motu has a large surface area of trauma associated with it. And unfortunately, many of the deaths were associated with rural distant deaths with long protraction times into a relatively small peripheral hospital.

So, it created challenges to us to try and build an improvement programme that would address that and highlight the need for us to reduce deaths that were preventable in trauma.

Carl: So, is that to say that the data was suggesting more people were dying than there should be and that there was variation in people dying across the country?

Dr Gunn: Yes, well, I think because, as I alluded to, our large population spread across a large area – New Zealand does have a high degree of trauma deaths compared to comparable countries, say, in Australia. And that offered us an avenue to try and reduce that.

What we know in New Zealand from data that we gained from the Trauma Network database in 2019 is that there were around about 2,300 cases of severe trauma, major trauma that were occurring in New Zealand, of which 8.4 percent of those, 198, were dying. That is a higher number than we would hope, but it was representative on what you would expect in New Zealand. Twenty-five of those deaths were associated with haemorrhage. We know that it's the population that our bundle approached and tried to reduce.

And that's quantifiable amounts of preventable deaths that we had to work with in New Zealand. To reduce that down would be a very significant improvement in our health care for these types of patients.

Carl: So, to reduce that number of people dying from blood loss, that was one of the goals. What were the solutions that you identified to achieve that goal? I think you mentioned a bundle just now.

Dr Gunn: That's right. So, if you look at this, it’s a complex scenario. These patients are being injured across the country, often distant to both ambulance and hospital care. They are critically injured, therefore they represent to us our highest risk of death. These groups represent 60 percent of our major haemorrhage deaths in the first four hours after arriving at a hospital. So, time is of the essence to try and treat these patients better.

So, we needed to create a bundle that recognised these patients as being different to the ones that were not bleeding to death and create a universal language and understanding across all our colleagues from the site of injury through to hospital, to take these patients and treat them in a different way.

I think most international improvement programmes recognise that a bundle of care that's understood across different groups in the hospital is a health improvement strategy most likely to create success.

So, in 2019 we gathered together a group of New Zealand experts to build a bundle that was agreed across all the practitioners that care for this subgroup of patients. A language of understanding and a language and a process of treatment that would achieve two endpoints: one, to get the patient to a care delivery centre as fast as possible. That, in New Zealand, essentially means for these type of patients a hospital that can deal with major trauma and B, resuscitate and hold that patient in a life sustaining manner between the point of injury and that point of hospital.

So they were the overall points. The group that we brought together had to build a bundle within those constraints, referencing best world evidence and the resources that were available in New Zealand.

Carl: So, has that bundle and the improvement project around it had an impact on the number of people who are dying from critical bleeding?

Dr Gunn: Well, we believe it has.

It's been a difficult period of time to get accurate numbers associated with change in practice. We've gone through COVID, we've gone through a significant alteration in normal practice. But if you look at the four years of data since the rollout of the bundle, the amount of preventable haemorrhage death has been dropping from 10.6 percent in the year before the bundle was rolled out, to the low point last year of just over 5 percent. So, we've had around about halving in the amount of deaths associated with this subgroup of patients.

So, we believe we're getting close to enough data now to be confident that we've had a significant improvement in the care of these type of patients.

Carl: That's an extraordinary result.

You work in a large urban hospital and that has access to plenty of people resources, a large blood bank. How are things different for smaller regional hospitals?

Dr Gunn: Well, as I referred to earlier, this really brings the nubbin of the problems of dealing with these type of patients.

You can imagine the difficulty of having a patient that is likely to die within the next four to five hours of bleeding in a rural site, in a road traffic accident, in a peripheral road, long extraction time, hard to access. And quite often a two-stage process of a transport to a peripheral hospital and then ongoing transport to a metropolitan.

Most of these smaller hospitals have low amounts of resources… of blood products… because blood is a scant reserve in New Zealand that we cannot have in every single hospital. Part of the bundle even addresses putting blood on helicopters and in ambulances for this subgroup of patients. But getting it to those patients in need at the right time is still difficult and could easily lead to a lot of waste of blood products without really being able to address the issues of the patients that they're focused on.

So, it created a balance and the bundle, I think, went a long way to discussing where that balance is. What groups that resuscitation can be advanced towards and what groups we had to rely on the peripheral hospitals and the metropolitan hospitals for dealing with it.

Carl: So, there are differences in the resources hospital and emergency services have across New Zealand. What helped get agreement that the bundle would be the right thing for all patients no matter where the injury happened?

Dr Gunn: Part of it, and part of the strength of what we were able to create, was for the first time related to this topic. Practitioners all the way from paramedics at roadside through to emergency departments, through to operating room surgeons and anaesthetists and intensivists and blood transfusion specialists were all able to get together and work this bundle out together.

It created a common understanding of the problem. It created a pathway of language, of recognition. And very importantly, it created a bypass where the recognition that the patient was acutely ill and likely to die without care, meant that they bypassed what were normal holding strategies which would slow the patient’s transfer to that delivery environment, usually an operating room.

So, patients were getting to the operating room faster and alive, and that needed everybody working together.

Carl: Before the bundle, there must have been a lot of pressure on those smaller centres when they received a patient with major injuries.

Dr Gunn: This is stressful stuff. You very infrequently get patients this crook and they turn up on your doorstep and you don't have the resources to do it, you know.

So, the whole point of this was to offer a system to everybody up and down the country that gave them confidence when they trialled and practiced it that they were doing the right thing and if they needed the tools to add, whether that's personal education or physical capex or in certain circumstances blood they could get it.

But, you know, building a unity in the country of hospitals that don’t get this sort of stuff very often was a key part of the bundle.

Carl: What's next for this work?

Dr Gunn: Well, I think we are excited by the change and we have to reinforce that the change is permanent and that change goes on going.

If we look at what we've got potentially with the combination of haemorrhage deaths and patients that die from multi-system organ failure in intensive cares; we've got up to 50 patients that we could prevent a death in a five-year period. And that is an exciting proposition of an improvement project.

So, if that is where we are, we are halfway along that path, we've got the other half to go.

I think, too, we have created, I think, an understanding in a lot of hospitals in New Zealand of a bundle that is changing care. We need to reinforce the positivity of that to the groups. We need to look at the bundle, see where there are areas of improvement, see where there is areas of rollout to groups that we can assist with, so that we can maximise the benefit of that. And create a situation where this improvement continues.

We're excited that improvement projects like this seem when changing practice, to improve patient outcome; we're on a pathway that we need to both celebrate and keep on going.

Carl: Kerry, thank you for taking the time to speak with me and to share this work today. It's been a pleasure talking with you.

Dr Gunn: Thank you very much for having me.

Carl: Thanks for tuning into our kōrero with Dr Kerry Gunn today.

He's talked about how standardising care for managing critical bleeding in major trauma patients across the country has saved lives and provided the tools for trauma teams to respond more quickly and effectively.

If you'd like more information about this work, including the bundle and self-audit tools, head to the National Trauma Network website at www.majortrauma.nz. You can also find information about other work being done by the National Trauma Network and Te Tāhū Hauora Health Quality & Safety Commission to improve trauma care.

Thanks again for joining us.

Mā te wā.