Strengthening trauma care in China

China’s main healthcare burdens are shifting from infectious diseases and perinatal health problems to non-communicable diseases and injuries. Injury is a leading cause of death and disability for young people in China, mostly from road traffic injuries.1 The latest World Health Organization data (for2013) show that China has a higher incidence of road traffic related deaths (18.8/100 000 population) than the average for high and middle income countries (9.2 and 18.4 deaths per 100 000, respectively).2

Well organised trauma care systems in high income countries have been shown to substantially reduce deaths rates from injury, which may partly explain the considerably better outcomes after road traffic injury in these countries.3 China lacks these integrated systems (from pre-hospital care to rehabilitation), and deficiencies in elements of trauma care have hindered efforts to reduce the unacceptably high rates of injuries and deaths.

One pressing concern is the need for an adequately trained workforce to meet the complex needs of trauma patients. Training and certification for trauma are not fully developed in China. Many trauma patients receive care from an undefined workforce that includes bystanders, ambulance staff, and healthcare professionals with no specific training in trauma.45

Existing trauma services and resources are poorly distributed relative to need. Urban areas have the lion’s share, leaving extremely limited services in rural regions where rates of injury related deaths are higher (53.49/100 000 in rural populations v 37.63/100 000 in urban populations in 2015).1 Regional trauma services are also often unstructured and poorly matched to the needs of the local community.There is good evidence that specialised trauma centres and trauma teams can reduce injury related mortality.36 However, few large hospitals in China have a trauma centre or designated trauma team, even in major cities.5 These trauma centres are generally not fully developed and not well integrated with regional trauma services, partly because of a lack of national planning and guidance regarding designation, verification, and inspection. These deficiencies are obstacles to ensure that the right patient is managed in the right place, by the right team, at the right time. A networked model of trauma centres is needed to improve provision throughout China.

Well established guidelines and protocols governing, for example, triage, interhospital transfers, and massive transfusion can reduce unnecessary deaths, but they are not widely available or used in trauma care in China.78 The Trauma Association of China has stated that in most of the country both pre-hospital and in-hospital services lack standardised protocols to guide trauma care.7 Moreover, a lack of early and appropriate rehabilitation services for patients with injuries has contributed to large numbers of avoidable secondary complications and disabilities. Where available, rehabilitative trauma care is limited and rarely includes psychological treatments, occupational therapy, or speech therapy. One survey of 80 hospitals in eastern China found that only 4.7% (730) of 15 611 inpatients with traumatic brain injury received early rehabilitation services.9

One of the targets included in the Healthy China 2030 plan, released in October 2016 by China’s Central Party Committee and the State Council, is to decrease the proportion of fatal road traffic injuries to the same level as in “moderately developed countries” by 2030.10 This is to be achieved mainly through improvements to the emergency response.10

Successfully reaching this target will depend on the development of well organised, affordable, and sustainable trauma care systems to ensure quality and equity in trauma care across all regions of China. Action is required now, informed by WHO guidance11 and evidence from high income countries such as the US, Germany, and Australia about how to successfully reconfigure trauma services.3

International guidance, evidence, and experience have had little influence in the reform of trauma services in China to date. Although some work is under way—such as the trauma networks developed by the Peking University Trauma Medicine Centre, which could serve as a template for the rest of the country. Each network comprises one trauma centre in a qualified general hospital, and between four and six trauma rescue and treatment stations in nearby secondary hospitals selected on the basis of their locations, population distribution and density, and local demand for first response and rescue. Current initiatives are nearly all in the early phase and efforts need to be accelerated.712

China should take full advantage of available scientific evidence and successful domestic and international experiences to design and develop context appropriate trauma care systems to improve outcomes from injury. The priorities should be to provide competency based training programmes for providers at all levels (including the public); introduce specialised trauma teams, evidence based standard guidelines and protocols, and integrated rehabilitation programmes; adaptexisting trauma care services to suit China’s geography, population density, trauma epidemiology, and organisation of healthcare; and establish programmes to designate, verify, and inspect trauma centres within a regional trauma network throughout China.