tackling a million deaths: a path for trauma systems ... saftey amit gupta.pdf · • requires a...
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Tackling a million deaths:Tackling a million deaths:Paving a path for Trauma Systems Paving a path for Trauma Systems
Development in IndiaDevelopment in India
Amit GuptaAmit GuptaAdditional Professor of Trauma SurgeryAdditional Professor of Trauma Surgery
[email protected]@gmail.com
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Pt Jawaharlal Nehru First Prime Minister Republic of India
Rajkumari Amrit Kaur, First Union Health Minister Republic of India
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Our aim is Our aim is ““ to provide state of the art, efficient and compassionate traumto provide state of the art, efficient and compassionate trauma care, from resuscitation to a care, from resuscitation to rehabilitation, to all Acutely injured patients and those requirrehabilitation, to all Acutely injured patients and those requiring its specialized services. Develop patterns of ing its specialized services. Develop patterns of
teaching, training, research and preventive strategies related tteaching, training, research and preventive strategies related to injury of highest standard.o injury of highest standard.””
JAI PRAKASH NARAIN APEX TRAUMA CENTERJAI PRAKASH NARAIN APEX TRAUMA CENTERAIIMS, New Delhi Estd. 2006AIIMS, New Delhi Estd. 2006
• Level I ‐ State of the art Patient Care
• Trauma Education
• Trauma Research• Design Systems• Role Model
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AIIMSAIIMS
DELHI (2014)DELHI (2014)17,838,84217,838,842Delhi NCR (2013)Delhi NCR (2013)24,753,48624,753,486
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APEX TRAUMA CENTREAPEX TRAUMA CENTREAIIMS, NEW DELHI AIIMS, NEW DELHI
Injury Surveillance Data
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Initial Triage EDInitial Triage EDYEAR 2011 2012 2013
E.D. FOOTFALL 49894 55698 58923
DATA ANALYSED FOR 11752 12601 11814
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Gender DistributionGender Distribution2011,N = 11752 2012,N = 12601 2013,N = 11814
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Age DistributionAge Distribution
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Broad Classification by Cause of InjuryBroad Classification by Cause of Injury
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Mechanism of InjuryMechanism of Injury
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Who brought Injured Victims to Hospital?Who brought Injured Victims to Hospital?
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Who brought the R.T.I. Victims?Who brought the R.T.I. Victims?
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Vehicles used to bring patientsVehicles used to bring patients
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ReferralReferral
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Road Traffic InjuriesRoad Traffic Injuries
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Victims VehicleVictims Vehicle
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Motorized 2 wheelerMotorized 2 wheeler‐‐ Who is injuredWho is injured
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Helmet Usage by Status of PatientHelmet Usage by Status of Patient
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Unintentional/ Accidental InjuriesUnintentional/ Accidental Injuries2011, N= 42872012, N= 43912013, N= 4439
3503(81.5%)
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NATIONAL SCENARIONATIONAL SCENARIO
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Mortality data: Accidental DeathsMortality data: Accidental Deaths
National Crime Records Bureau, Govt. of India
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RTI: Disastrous ProportionsRTI: Disastrous Proportions• A Boeing 747 jet carries about 400 passengers
• Deaths in 2012 from road traffic accidents are equivalent to more than a jet crash every single day.
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Killer RoadsKiller Roads
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Trauma: Silent GenocideTrauma: Silent Genocide
Transport related Injuries
40%
60%
Falls (pediatric/ old age group)Work Place Trauma
Agricultural related traumaFire Arms, Intentional self harm
Assault, Fall of objectsBurns, DrowningNatural DisastersTerrorist Attacks
Possibility of “NBC” events
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Injury PyramidInjury Pyramid• Each Death ~ 30 Severely Injured
Patients– Will have considerable post injury
disability
– Brain Injury, Spinal Injury, Amputations
– 4 million
• Each Death ~ 70 Non‐Life threatening and minor Injuries
– 9 million
– Transport related traumaGururaj et al, NIMHANS, Bangalore
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Global Plan Global Plan
Road safety management
Safer roads and mobility
Safer vehicles
Safer road users
Post‐crash response
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Accidental Death and Accidental Death and Disability: Disability: Neglected Disease Neglected Disease of Modern Societyof Modern Society
White Paper White Paper –– 19651965Division of Medical SciencesDivision of Medical SciencesNational Academy of SciencesNational Academy of SciencesUS Senate & White HouseUS Senate & White House
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• Requires a broad framework of policies and protocols in a given geographical area
• Seamless transition between each phase of care, integrating health resources
• Team work between various agencies
‘‘Getting the right patient to the right place Getting the right patient to the right place at the right time for the right careat the right time for the right care’’
Care of the severely InjuredCare of the severely Injured
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Very high mortality and morbidity (16 times) for the same Injury severity in India as compared to western data
– Primitive or no existence of TRAUMA SYSTEMS
– Lack of dedicated Pre‐hospital care
– Absence of trained manpower in Prehospital; In‐hospital Acute trauma care and rehabilitation
– Lack of Trauma related hospital data (registry) and Trauma Quality improvement programs.
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PRE HOSPITAL CARE
IN HOSPITALACUTE CARE
IN HOSPITALDEFINITIVE
CARE
REHABILITATION
RESUSCITATION TO REHABILITATIONTRAUMA CENTERS CANNOT FUNCTION ALONEHAVE TO BE A PART OF TRAUMA SYSTEM
TRAUMA CENTRE / TRAUMA SERVICES
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Assessment of Critical GapsAssessment of Critical Gaps
• Physical Resources: Infrastructure, Equipment and
Technology
– Medical Care
– Communication
• Human Resources: Staffing and Training
• Process: Organization and Administration
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Pre Hospital Care Pre Hospital Care –– India Lives India Lives in 2 Centuries Simultaneouslyin 2 Centuries Simultaneously
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PrePre‐‐Hospital Scenario Hospital Scenario –– Rural IndiaRural India
• Virtually non‐existent in most rural and semi‐urban areas in
India
• ‘Golden hour' concept is still an unachieved goal
• Gross discrepancy in pre‐hospital services between urban
and rural settings, as well as between paying and non‐paying
patients.
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• Physical Resources– Formal Ambulance licensing not
mandatory• Poor Quality – Ill equipped ambulances
– Multitude of organizations• Government• Police• Fire brigades• Hospitals• Private agencies
– No Single number exists– Absence of robust and centralized
communications center
PrePre‐‐Hospital Scenario Hospital Scenario –– Urban IndiaUrban India• Human Resources
– Absence of cadres of paramedical staff
– Absence of minimal educational and training standards for paramedics
• Organization– Absence of guidelines
• triage, patient‐delivery decisions, pre‐hospital treatment plans and transfer protocols
– No Integrated EMS/Trauma Council
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Definitive Trauma Care ScenarioDefinitive Trauma Care Scenario• Physical Resources– Definitive Trauma Care
– Government hospitals– Corporate hospitals – Small clinics across the country
– Government Sector– Have to cater to enormous numbers– Free, but quality of Care very variable– Most University Hospitals fulfill the criteria of Level I Facility» Acute care Infrastructure/ ED (Weak Link)
– Corporate Hospitals– Good Infrastructure but no numbers (Insurance penetration
Low)– Located in Large cities– No norms to govern standards & relations with the public
trauma system
– Mushrooming of Small Trauma Centers
• Human Resources– No trained Manpower in Acute care of Injured
• Medical Professionals
• Nursing
– Absence of ED Protocols
– Level of training and experience in providing life support is not uniform
– Dedicated Trauma teams ??
– No dedicated Trauma surgeons/ ED Physicians/ Nurses
• Result – Responsibility is not clearly defined
– Clinical decisions are often delayed
– Absence of clear perceptions of clinical responsibility amongst specialists
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Gap AnalysisGap AnalysisPre-Hospital Care In-Hospital Acute
Care
Rural/ Semi Urban
Urban Rural/ Semi Urban
Urban
Infrastructure - + ± +
Trained and Skilled Manpower
- ± - ±
Organization - - - -
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National Trauma PolicyNational Trauma Policy
• “Guidelines on Essential Trauma Care” – 2004– Low and Middle Income Countries
• First National Consultation on Essential Trauma Care ‐ Ahmedabad 2005– Laid down the thrust areas for National Trauma Policy
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National Trauma Policy National Trauma Policy –– Thrust AreasThrust Areas• Improvement in Health care Infrastructure at rural levels• Strengthen organizational aspect – Establish Trauma Systems
– Pre Hospital– Information Transfer and communications– Inter‐facility Transfer– Protocol Development
• Trauma Education / Interest Generation– Pre‐Hospital– Definitive Care
• Rehabilitation• Evaluation and Research (Trauma Registries)
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PrePre‐‐hospital Carehospital Care• Pre Hospital Care being given by
a private agency with a common number “108”
• Adopted by 12 States and is in different phases of Commissioning
• ALS + BLS
• Short Term Trained personnel
• Communications Center with GPS enabled systems
No Legislation/ EMS Body to govern and AuditSustainability??
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Definitive Trauma CareDefinitive Trauma Care
India's largest highway project for capacity enhancement of NatiIndia's largest highway project for capacity enhancement of National Highways by four/ six laning of onal Highways by four/ six laning of around 13,146 Km. around 13,146 Km.
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4 levels of Trauma Care4 levels of Trauma Care• L IV – Ambulance every 50 Kms
– 271: NHAI• L III ‐ Every 100‐150 Kms along the NH – Initial evaluation &
stabilization to trauma patient– 157 Level III Centers
• L II ‐ Every 300 Kms – Definitive care for severe trauma patients ( Existing medical colleges)– 74 Level II Centers
• L I ‐ Each and every state with highest level of definitive and comprehensive care of patient with complex emergencies. – 27 level‐I trauma centers will be established
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CAPACITY BUILDING CAPACITY BUILDING –– Manpower TrainingManpower Training
• Manpower training through short term courses like: PHTLS; AIIMS‐BECC; ATLS; ATCN;AUTLS; Rural Trauma Team Development Course
• Long Term Capacity building: MS (Trauma Surgery); MD (Trauma Intensive Care); M.Ch (Trauma Surg. & Critical Care)
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DEVELOPMENT OF A HOSPITAL BASED TRAUMA DEVELOPMENT OF A HOSPITAL BASED TRAUMA REGISTRY AT APEX TRAUMA CENTER, AIIMSREGISTRY AT APEX TRAUMA CENTER, AIIMS
•Basic Identification data•Unique Hospital number•Demographic profile•MLC/ Non‐MLC •Detailed Event description (not coded by ICD 10 at present)•Description of brought by personnel and vehicle (eg. Trained v/sUntrained; Ambulance v/s Non‐Ambulance)•Direct attendance or Referred case •Condition at time of arrival (including physiological parameters)•ED Interventions performed•Detailed Diagnosis (coded as per AIS 2005 – Update 2008) (Coding as per ICD10 not yet started)•Definitive Surgeries/ Procedures•Disposition/ Outcome (Discharge/Death/ LAMA/ Abscond etc.)
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Other Trauma Systems Research InitiativesOther Trauma Systems Research Initiatives
Towards improved trauma care outcomes in India• Karolinska Instituet, Sweden• Tata Institute of Social Sciences• JPN Apex Trauma Center, Delhi• LTMMC, Mumbai• Chennai• Kolkata• Srinagar
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Trauma Systems Research InitiativesTrauma Systems Research Initiatives
Reducing the burden of injury in India and Australia Reducing the burden of injury in India and Australia through development and piloting of improved through development and piloting of improved
systems of caresystems of care
Research Project will run for the next four yearsTry to find the best ways of delivering needed care to injured people
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Multipronged ApproachMultipronged Approach
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“Success is going from failure to failure without loss of enthusiasm”
Daunting, Challenging &
Exciting
FutureFuture
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