Trauma – getting the TU trauma team right

James Raitt, Rory Carroll, John Lee.

It is 0130 in a trauma unit in a hospital in a small town in England.  A trauma pre-alert is received from the ambulance service for an adult male who has been hit by a car and a hospital trauma call is put out.  The team gather in the resus room and the team leader Rebecca, an ST5 in Emergency Medicine, asks the assembled team to introduce themselves by their name and role.

“Hi, I’m Ahmed ST5 in anaesthetics, I’ll manage the airway”

“Rosie band 6 ED nurse”

“Hi I’m Joe F2 in orthopaedics – by the way I’ve never been to a trauma call before, I’m planning to be an opthalmologist”

Rebecca asks if there is anyone present from general surgery to complete the team, but Joe thinks that they are at a NEWS call on the surgical ward.

Classical vs. actual trauma teams

The classic trauma team composed of senior doctors from EM, ITU, surgery and orthopaedics along with ODPs and ED nurses works well in the high volume, high acuity setting of a Major Trauma Centre (MTC) but across the UK we have tried to export this model into Trauma Units (TUs) some of which may see low volume and mostly low acuity trauma patients. There are a number of challenges associated with the application of the existing trauma team model to some TUs. 

Some of the team members, especially the more junior ones such as those doctors covering orthopaedics and surgery out of hours may have career aspirations outside of the traditional trauma specialties and are less likely to have received formal trauma training, either externally such as an ATLS course, or internal training which can be challenging to deliver to doctors on short rotations. A 2021 study by Bokhari et al, found that only 37% of trauma team members in TUs held valid trauma qualifications compared to 69% in their neighbouring MTCs¹.   A number of TUs may not have a senior doctor in orthopaedics or surgery resident in the hospital, although a senior resident in anaesthesia or ICM is usually present but may well have commitments to obstetrics or ITU as well as trauma.

The pre-test probability of serious injury can be much lower in a TU, in one local centre only 14% of trauma CTs showed any injuries and this can result in an expectation of low acuity.  Patients with high energy time critical injuries are preferentially transported to MTCs in accordance with ambulance service bypass criteria whereas patients who present to TUs may be older and have delayed presentations which still need treatment but may be less time critical. In addition out of hours trauma team members from inpatient specialties may well be the only doctor responsible for a number of ward patients who may also have urgent clinical needs, affecting their ability to attend trauma calls.

So what is the right model for a trauma team in a TU in 2025? 

Is it to just export the model used in the regional MTC, is it to change the model to suit the case mix and acuity of the patients that usually present but this brings the challenge that occasional patients of higher acuity will come through the front door, often with little or no warning.  How about training – do we try and train a large number of rotational staff, some of whom are on 4 month placements and by the time the training has taken place there are only a couple of weeks of the role left?  Do we try and create a smaller but more focussed group who respond to trauma – who should these individuals be, do they need to be doctors?  How many members do you need in a trauma team – the traditional model has around six to ten members but actually we see excellent care and advanced interventions delivered by three person prehospital critical care teams by the roadside.  So many questions, and few answers. 

Trauma team presence and composition varies hugely throughout the globe. A recent study demonstrated that only 61% of hospitals studied worldwide had dedicated trauma teams². A survey in Italy found that only 39% of the “Centro Traumi di Zona” (district general hospitals with trauma capacity similar to the UK TU) had formally defined trauma teams³ whilst in New Zealand, 75% of all hospitals studied had a trauma team, with sizes ranging from 6 to 17 members⁴. The presence of trauma teams does appear to reduce mortality rates⁵, but in what guise they should appear, nobody seems to have the answer!

Many TUs have a two tier system with a full hospital trauma call for those with significant mechanisms or physiological derangement and an ED trauma call (or tier two or in house) response for cases of lower perceived severity.  Some centres use ACPs or paramedics employed within the Emergency Department as part of their trauma team, others have had success in reducing the pool of staff providing trauma interventions leading to greater consistency and improved teamworking.  There is a lot of talk about teamwork in trauma, but how often in a low to medium volume centre have the members of a trauma team ever trained together before they meet at a trauma call, will that team ever work together again? In reality these are flash teams – meeting and working together at a single event before returning to their daily role, perhaps left with questions, suggestions or unmet educational needs and often not knowing what the outcome of the patient was.

We think we can do better, for our systems, for our team members and for our patients; but there are many questions and few clear answers.  However we should ask ourselves – what does good look like?  Does the existing system provide that – in working hours? At night?  How would we amend our system to deliver the care that we would want for our families?

What does the data tell us about the UK position?

In order to address the question of whether the traditional trauma team model meets the needs of patients and staff in our trauma network in 2025 we surveyed 151 staff from TUs across the trauma network including site trauma leads, trauma team leaders (TTLs) and trauma team members (TTMs). Three linked questionnaires were distributed across the Network, involving a range of single-answer, Likert scale, and open text questions; exploring trauma call activation criteria, leadership, attendance and training as well as respondents’ perceptions and suggestions for improvement. 

The key themes identified were concerns regarding team engagement, attendance, experience and training. Only 20% of site trauma leads felt the current system worked well for their trust. While TTLs felt confident overall to manage the challenges of trauma, they noted difficulty with attendance from the full team. 33% of TTM respondents had no formal trauma training. Only 39.1% of non-EM respondents felt that the trauma team system worked for their hospital, and more junior members expressed concerns regarding their role and value. 

How can we improve?

• Strong ED team leadership is the key modifiable factor.  TUs must support trauma team leader training and development. 
• Use the zero point survey to establish leadership and clear allocation of roles and expectations

• Deliver whole hospital in situ high fidelity multi-disciplinary simulation.
• Trauma team members need training as part of induction to the role – Network online training module and TU specific orientation as a minimum. 
• Hospitals to review the make up of the trauma team to ensure that: 
• There is input from specialty decision makers rather than junior members of the specialty team who need to seek advice.
• The pool of team members is as small as possible to increase engagement and exposure.

What about TU structures and training?

• Greater involvement of critical care outreach teams or specialist allied health practitioners in trauma calls as formal members of the team. 
• Surgical specialty representation at Registrar level to allow expert advice to be given. 
• Add clarity around the use of two tier or inhouse trauma calls 
• Hospitals are encouraged to develop training for the whole team, beyond ATLS and to encompass all relevant specialties, not just those who work in the ED. 

We identified that the current trauma team model may not be optimal for TUs our network. Areas for improvement were identified as team engagement, attendance, experience, training, and confidence, particularly among more junior staff. Modifiable factors were identified as strong team leadership and focused multi-specialty training through simulation, with scope to improve the formal and informal training of TTMs. We hope our findings might prompt you to consider what happens in your hospital or network and whether a similar survey might be useful in improving the response of trauma teams in trauma units.  Your thoughts and comments on this blog piece are welcome.

Thanks for reading,

James Raitt, Rory Carroll, John Lee.

References:

1. Bokhari, S., Aslam-Pervez, N., Riaz, O., Sadozai, Z., Bhamra, M. & Harwood, P. (2021) ‘What effect has the major trauma network had on perceptions of trauma care delivery amongst trauma teams in major trauma centres and neighbouring trauma units?’, European Journal of Trauma and Emergency Surgery, 47(1), pp. 171–177. Available at: https://doi.org/10.1007/s00068-019-01206-1.
2. Bento, A., Ferreira, L., Benitez, C.Y., Koleda, P., Fraga, G.P., Kozera, P., et al. (2022) ‘Worldwide snapshot of trauma team structure and training: an international survey’, European Journal of Trauma and Emergency Surgery, 49(11), pp. 1–11.   
3.  Carenzo, L., Locatelli, C., Ciceri, F., Pisano, M., Cimbanassi, S., Raimondi, F., et al. (2024) ‘State of the art of trauma teams in Italy: A nationwide study’, Injury, 66, p. 111388
4. Lynham, R., McGuinness, M.J. and Harmston, C. (2022) ‘Trauma Teams in Aotearoa New Zealand-a national survey’, The New Zealand medical journal, 135(1560) 
5. Gerardo, C.J., Glickman, S.W., Vaslef, S.N., Chandra, A., Pietrobon, R. and Cairns, C.B. (2011) ‘The rapid impact on mortality rates of a dedicated care team including trauma and emergency physicians at an academic medical center’, The Journal of Emergency Medicine, 40(5), pp. 586–591.
6. Iain Beardsell, “Trauma Team Leadership – Top Tips from Ten Years of Trauma Team Leadership,” in St.Emlyn’s, March 29, 2022, https://www.stemlynsblog.org/top-tips-from-ten-years-of-trauma-team-leadership/.
7. Iain Beardsell, “Trauma Team Leadership – Top Tips from Ten Years of Trauma Team Leadership,” in St.Emlyn’s, March 29, 2022, https://www.stemlynsblog.org/top-tips-from-ten-years-of-trauma-team-leadership/.
8. Iain Beardsell, “Podcast – Trauma Team Leadership,” in St.Emlyn’s, July 8, 2015, https://www.stemlynsblog.org/podcast-trauma-team-leadership/.
9. Simon Carley, “Podcast – Trauma Team Leadership – Getting to CT in 30 minutes.,” in St.Emlyn’s, July 8, 2014, https://www.stemlynsblog.org/ttl-podcast-1-getting-ct-30-minutes/.
10. Simon Carley, “Introducing the Trauma Team Leader Tips (TTL Tips) Series,” in St.Emlyn’s, November 26, 2025, https://www.stemlynsblog.org/introducing-the-trauma-team-leader-tips-ttl-tips-series/.