Lesson Learned from Trauma Care System

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1 Lesson Learned from Trauma Care System Dr Sabariah Faizah Jamaluddin Senior Consultant and Head Department of Emergency & Trauma Sungai Buloh Hospital MALAYSIA

2 Trauma Care System Organized approach to acutely injured patients in a region that provides optimal care and is integrated with the emergency medical services Regionalization of trauma care facilitates efficient use of health care facilities, equipment and resources Major goal to decrease incidence of injury and decrease injury related morbidity and mortality

3 Percent change in age-standardised road injury disabilityadjusted life year (DALY) rates Disproportionate distribution of injury-related (DALY) especially in the age group of years of injury, Haagsma, J.A. et al., 2015 Global Burden of Disease study 2013

4 Trauma is an epidemic that affects all age groups with personal, psychological and economic consequences Despite the significant toll of injury, policy responses for both prevention and improvement of trauma care system have been minimal in most countries

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8 Trauma Care Systems in place around the world

9 LEADERSHIP SYSTEM DEVELOPMENT LEGISLATION FINANCE

10 Prehospital Trauma Care System Involves getting the right patient to the right place in the right amount of time Focused on initial resuscitation, triage and transport of patients In rural and developing countries involve setting up a prehospital trauma care service Developed countries improvements in existing infrastructure, access to prehospital trauma care, ambulance diversion protocols and training of paramedics

11 Ghana birth and growth of the National Ambulance Service Before the year 2000 informal and limited prehospital care High numbers of fatalities from road traffic accidents mortality rates up to 80% in the prehospital care setting Establishment of the National Ambulance Service (NAS) to provide effective prehospital care and transfer in 2004 Training of EMTs from National Fire Service and Ministry of Health Dedicated emergency line - 193

12 Key performance indicators show an improvement in quality of care Reduction in mean response time from 17 minutes in 2006 to 13 minutes in 2008 Reduction in vehicle engaged times (time from dispatch until return to station and ready for next run) decreased from 3 hours 7 minutes in 2006 to 2 hours 8 minutes in 2008 Ministry of Health of Ghana. Policy brief on National Ambulance Service,

13 Mexico strengthening basic emergency medical services In the state of Nuevo Leon, steps were taken to improve: Infrastructure increased number of ambulance dispatch sites Access universal emergency telephone number 911 eliminated delays in access of care Training establishment of Prehospital Trauma Life Support for paramedics, development of qualification programs for paramedics to become EMTs Arreola-Risa C et al. The effect of emergency medical technician certification for all prehospital personnel in a Latin American city. Journal of Trauma, 2007, 63(4):

14 Prehospital Trauma Care in Germany Able to deal with injured young individuals as well as with an increasing number of injured elderly patients. To perform technical and medical therapy at highest available level as soon as possible, a ground system of physician staffed ambulances is supported by a network of physicianstaffed Helicopter Emergency Medical Service (HEMS) all over Germany Enormous efforts in financing, basic research and quality management have been undertaken during recent years to create such a sophisticated prehospital trauma care system. These efforts appear to have been rewarded; mortality for major trauma patients have fallen from 40% to less than 20% Trauma care in Germany. Westhoff J et al. Injury, Int. J. Care Injured 34 (2003)

15 Trauma Centers Equipped and staffed to provide care for patients suffering from major trauma such as falls, road traffic accidents and gunshot wounds Official designation as a trauma center is determined by individual state law provisions Trauma centers vary in their specific capabilities The highest levels of trauma centers have access to specialized care including emergency medicine, trauma surgery, critical care, neurosurgery, orthopedic surgery, radiology as well as highly sophisticated surgical and diagnostic equipment Lower levels of trauma centers may only be able to provide initial care and stabilization of a patient and arrange for transfer to a higher level of trauma care The operation of a trauma center is extremely expensive

16 United States Evaluation of the effect of Trauma Center care on mortality

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19 Canada Improving the Trauma system in Quebec In between , approximately 53 out of people die annually from trauma Trauma care clinicians and the state government implemented a trauma registry in the province which eventually included all admissions in any hospital for trauma Further development of the trauma care system was done using data from the registry Reduction in prehospital times Ambulance diversion to dedicated trauma centers Upgrade in existing infrastructure of the trauma centers Guidelines for interhospital transfer and rehabilitation facilities Overall cost for maintaining the Quebec trauma system were low and sustainable (less than 1% of the state health budget)

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21 In the UK a 30% reduction in mortality rate and improvement of mortality rate achieved with formation of trauma networks. TRAUMA AUDIT AND RESEARCH NETWORK (TARN)

22 Training of Human Resource Qatar has one of the highest road traffic death rates in its region Overall system and state of organization for handling trauma patients was not sufficient to deal with the increasing numbers Inception of a special dedicated Trauma Service in 2007 Multidisciplinary approach involving a trauma team Supported by a trauma nurse coordinator and trauma registry personnel who enter clinical data and analyze the program

23 Substantial improvement in the structure of care Increased training levels of members of the team that cares for the injured More readily available equipment and supplies Organized framework for the delivery of care Time from arrival of the patient in the resuscitation unit to the operating theater has been reduced from 60 minutes to 30 minutes

24 Rehabilitation In Brazil large number of people severely disabled by road traffic accidents Acute care hospitals have an innovative rehabilitation team which Provide consultation for patients soon after admission Early rehabilitation exercises including for family members No delay in initiating therapy while awaiting transfer to a separate facility Dramatic reduction in pressure sores, urinary tract infections and joint contractures

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26 Gujarat state physical rehabilitation assistance to earthquake victims In Gujarat, India earthquake in 2001 left a large number of people with paraplegia State health services developed a programme for better availability of rehabilitation services such as wheelchairs, assistive devices and manpower in the rehab facilities, clinics and community Reduction of 5 year mortality among paraplegics from 60% to 4%

27 COST OF TRAUMA CENTRES

28 Trauma Registry and Research Databases that document acute care delivered to patients hospitalised with injuries Designed to provide information that can be used to improve the efficiency and quality of trauma care Allow opportunities for the evaluation of patient outcomes and inter-hospital comparisons However, the creation and upkeep of trauma registries requires a substantial investment of money, time and effort Combination of trauma registry data at regional or national levels can produce very large databases History and development of trauma registry: lessons from developed to developing countries. Nwomeh B et al. World Journal of Emergency Surgery 2006, 1

29 Multicenter International Registry Pan-Asian Trauma Outcomes Study Established in 2013 by 11 Asia-Pacific countries to build an international retrospective registry of trauma Integrate separately kept trauma data in Asia into a single, international registry Serve as a platform to stimulate comparative research and inform effective trauma policies and practices Improve trauma outcomes through community and system level interventions

30 Recognition of the continuum of care required Regionalization of trauma care Disaster preparedness Critical Targets for Development of Future Trauma Care Systems Coordination of resources and improving cost effectiveness Identification of trauma as a disease process Reimbursement, funding, and legislation Recognition that trauma requires a multidisciplinary approach Trauma System Agenda for the Future, NHTSA, 2002.

31 Conclusion Changes in the trauma systems took decades to implement Better organization and planning results in better achievements in quality improvement Can be cost effective and sustainable feasible not only for countries with financial resources but even those with limited resources Data collection necessary to convince policy makers of the extent of the toll of trauma and the need for improvements which are evidence based, as well as for monitoring and evaluation

32 Thank You

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