trauma training: where do we spend money to get best results kris arnold, md, mph, facep asst...
TRANSCRIPT
Trauma Training: Where Do We Spend Money to Get Best Results
Kris Arnold, MD, MPH, FACEPAsst Professor Emergency Medicine (retired) Boston University School of Medicine
Disclosures
• None
Objectives
• Explore the points in the chain of trauma response and care for the most cost-effective training points for improving outcomes.
• Explore options that have been employed in other resource-constrained developing trauma response systems.
Trauma Care
Event
Self/
Bystander
Pre-hospital care
(transport)
Emergency Department
In-hospital (acute care
+ rehab)
Post-hospital
Points of Intervention to improve outcome
Phase Human Vector Environment
Pre-Event Driver EducationTask training
Vehicle design and maintenance
Highway design
Event Reaction Vehicle safety features
Road safety barriers
Post-Event Medical Response
Gas tank seal Road quality for health care access
Factors
The Best Bang for your Buck
Field ED
In P
atie
nt0
5
10
15
20
25
30
35
40
Where/when is it happening
Arreola-Risa C, Mock CN, Padilla D, Cavazos L, Maier RV, Jurkovich GJ. Trauma care systems in urban Latin America: the priorities should be prehospital and emergency room management. J Trauma. Sep 1995;39(3):457-462.
Mortality
11
40
21
3.36 7
(ISS ³9)
Seattle, USA(n=533)
Monterey, Mexico(n=545)
Definitive Care Proximity
Viet Duc
St PaulBach Mai
Nagata T, Takamori A, Kimura Y, Kimura A, Hashizume M, Nakahara S. Trauma center accessibility for road traffic injuries in Hanoi, Vietnam. J Trauma Manag Outcomes. 2011;5:11.
No Surprise Distance to VD =>
Mortality
Not Only Road Crashes
Vietnamese burned while on phone at gas stationPosted on October 25, 2012 Skyscraper on fire, 11 injured in
Vietnam capitalPosted on October 25, 2012
Cold wave unrelenting in Northern RegionPosted on January 4, 2013
Hospitals in Hanoi, like the National Hospital of Pediatrics, Bach Mai and Saint Paul, are also treating a large number of people with weather related ailments.
http://talkvietnam.com
Emergency Care Proximity
Population2011
RuralUrban
Rural69%
Urban31%
Injury Treatment Location Rural Vietnam
Hang HM, Byass P. Difficulties in getting treatment for injuries in rural Vietnam. Public Health. Vol 123. England 2009:58-65
Distance from care was also positively associated with not getting care.
Catastrophic Costs
WHO. Designing health financing systems to reduce catastrophic health expenditure. Geneva: WHO;2005Hang HM, Byass P. Difficulties in getting treatment for injuries in rural Vietnam. Public Health. Jan 2009;123(1):58-65.
Rich Poor Very Poor02468
1012141618
Affordable health expenditure ≈ 5% total household incomeWHO defines catastrophic health care cost as ≥ 50% disposable income
7.4
13.2
16.9
% Household Income spent on injury care
Who can give care?
Event
Self/
Bystander
Self / bystander Care
Pre-hospital care
(transport)
Emergency Department
In-hospital (acute care
+ rehab)
Post-hospital
Untrained Provider
None Family CompanionsPassersby
52%
33%
19%
19%
Trauma Care in Hanoi
Nguyen TL, Nguyen TH, Morita S, Sakamoto J. Injury and pre-hospital trauma care in Hanoi, Vietnam. Injury. Sep 2008;39(9):1026-1033.
Note total %>100 since some victims received assistance from person of more than one group
Bystander Effect
He does not really need
helpHe will be OK
I am sure someone
else will take care
He is probably
drunk
Pre-hospital care (transport)
Scene to Hospital Transport
Emergency Department
In-hospital (acute care
+ rehab)
Post-hospital
Event
Self/
Bystander
TransportProfessional Care
Trauma Care in Hanoi
First Aid Provider
Commune Health Worker
14%
Nguyen TL, Nguyen TH, Morita S, Sakamoto J. Injury and pre-hospital trauma care in Hanoi, Vietnam. Injury. Sep 2008;39(9):1026-1033.
Improving the Picture
Pre PHTLS Post PHTLS0
2
4
6
8
10
12
14
16
Mortality (%)
Ali J, Adam RU, Gana TJ, Williams JI. Trauma patient outcome after the Prehospital Trauma Life Support program. J Trauma. Jun 1997;42(6):1018-1021.Arreola-Risa C, Mock CN, Lojero-Wheatly L, et al. Low-cost improvements in prehospital trauma care in a Latin American city. J Trauma. Jan 2000;48(1):119-124.
Effect of Pre-Hospital Trained Intervention
• Slightly greater effect in rural areas versus urban areas
Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta-analysis. J Trauma Acute Care Surg. Jul 2012;73(1):261-268.
Untrained Trained0
20
40
60
80
100
120Mortality
- 25%
Truck Driver First Aid - Ghana
Before Training After Training0
5
10
15
20
25
30
35
40
45
Scene ManagementAirwayExt BleedingSplinting Limb
Mock CN, Tiska M, Adu-Ampofo M, Boakye G. Improvements in prehospital trauma care in an African country with no formal emergency medical services. J Trauma. Jul 2002;53(1):90-97
Self-reportNo outcome data
In-hospital trauma care
Emergency Department
Post-hospital
Event
Self/
Bystander
Pre-hospital care
(transport)
Emergency DepartmentInpatient Care
Meeting the need
• Hanoi Health Service
• The emergency service centre and hospitals in Hanoi can meet only 3.9% of emergency needs
Hanoi Health Service. Annual Injury Prevention Report; 2006
Resource MatchingSystem Level Commune District Province/City Central
Unit CT/DL VN/TG Hanoi
CR/Vni DA/SS Hanoi
KH SP Hanoi
VDHanoi
Inpatient Beds 1 0-2 70-165 200 550 500 500
Inpatients/yr 120 200 1930 1200 3800 2000 14,000
% Trauma 10 3 48 50 23 25 50
Total Trauma 12 6 926 600 874 500 7,000
Doctors with Trauma Training*
0 0 63% 83% 25% 50% 60%
Nurses with Trauma Training*
20% 0 31% 24% 25% 25% 70%
Son NT, Thu NH, Tu NT, Mock C. Assessment of the status of resources for essential trauma care in Hanoi and Khanh Hoa, Vietnam. Injury. Sep 2007;38(9):1014-1022.
• Relatively low frequency of cases in commune/Province/City suggests may have more need for primary trauma care training due to degradation of skills with non-use
• 8,106 trauma cases/yr for Hanoi population of 6 million = 22 trauma hospitalizations/day
So What to Do
Physicians & Nurses
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
2
4
6
8
10
12
14
Physicians
Nurses
Practitioner / 10,000 population
World Health Organization, World Health Statistics 2012. http://www.who.int/healthinfo/EN_WHS2012_Full.pdfMinistry of Health – Five Year Health Sector Development Plan 2010-2015 http://www.wpro.who.int/health_services/viet_nam_nationalhealthplan.pdf
12.2
10.1
Note: Vietnam MoH reports 7 doctors/10,000 projected for 2010
Health Resources
Nurses Physicians Hospital beds0
20
40
60
80
100
120
USFranceVietnamChinaCubaCanada
Per 10,000 population
Health Care Education Cost
• Thai Binh, Bach-Thai, Hai-Phong (1997-1999)
• Total cost/medical student – 9,527 USD
• Physician training ≈ 14 X Nursing training
• First aid ??
Bicknell WJ, Beggs AC, Tham PV. Determining the full costs of medical education in Thai Binh, Vietnam: a generalizable model. Health Policy Plan. Dec 2001;16(4):412-420.
Relative Training Cost
Physician*Nurse*EMT**First Aid***
*Bicknell WJ, Beggs AC, Tham PV. Determining the full costs of medical education in Thai Binh, Vietnam: a generalizable model. Health Policy Plan. Dec 2001;16(4):412-420.**Relative pricing based on average of several US EMT tuition rates***Based on relative cost of American Red Cross Advanced First Aid course to cost of 4 years medical school in US
The Human Factor
District medical clinics not patronized by local residents“…shortage of good doctors and inadequate facilities”
http://talkvietnam.com/2013/01/healthcare-sector-hampered-by-poor-quality-training/#.UQUyXWewWSo January 11, 2013http://talkvietnam.com/2012/12/district-medical-clinics-not-patronized-by-local-residents/#.UQUzAmewWSo December 18, 2012
Director of the MoH’s Science and Training Department Nguyen Cong Khan said that even if the number of students who graduated from medical schools by 2020 doubled, they would still fail to meet the demands of the healthcare sector.
However, at present the rate in the Cuu Long (Mekong) Delta is 5.27/10,000 and in some provinces it is even lower, such as SocTrangProvince at 3.78/10,000 and HauGiangProvince with 4.05/10,000.
Resource Upgrade
System Level Commune District Province/City Central
Unit CT/DL VN/TG CR/Vni DA/SS KH SP VD
Doctors with Trauma Training*
0 0 63% 83% 25% 50% 60%
Nurses with Trauma Training*
20% 0 31% 24% 25% 25% 70%
Ambulances Pvt Pvt 1DH Pvt
1DH Pvt
5 5 5
Son NT, Thu NH, Tu NT, Mock C. Assessment of the status of resources for essential trauma care in Hanoi and Khanh Hoa, Vietnam. Injury. Sep 2007;38(9):1014-1022.
*Trauma training at post graduate level = advanced specialization related to trauma or continuing education course on trauma care
Level of Pre-Hospital Intervention
• Mexico– Arreola-Risa results
• No improvement in mortality w/ ALS– Arreola-Risa C, Mock C, Herrera-Escamilla AJ, Contreras I, Vargas J. Cost-
effectiveness and benefit of alternatives to improve training for prehospital trauma care in Mexico. Prehospital Disaster Med. Oct-Dec 2004;19(4):318-325.
• Developed countries– No advantage to ALS
• Worse mortality w GCS<9 – Stiell IG, Nesbitt LP, Pickett W, et al. OPALS Study Group. The OPALS major trauma
study: impact of advanced life-support on survival and morbidity. CMAJ. 2008;178:1141-1152.
Scoop ‘n Run vs Stay ‘n Play
Bottom Line• All sectors could use more persons trained in
organized emergency and trauma response– Continuing and upgrade education for people already
working in health care with likelihood to care for emergencies and trauma
• The use of first responders with minimal training has been shown to decrease mortality– First responder training is much less costly than
training professionals
• This all needs to be in the context of developing the protocols and infrastructure for an organized approach to emergency care – Regional EMS
Mandate for the Future
• Focus on raising quality of treatment in district hospitals across the country so as to help in reducing overloading in central hospitals.– doctors from the bigger hospitals to visit
clinics in the countryside to share their skills
• Imbibe a sense of responsibility in medical staff– emphasised that medical ethics is connected
with a sense of responsibility.
Ordered the health sector to:
Prime Minister Nguyen Tan Dung Hanoi January 24, 2013
online meeting to review the health sector’s mission in 2012 and plans for 2013
http://talkvietnam.com/2013/01/pm-asks-health-sector-to-adopt-high-ethical-standards/#.UQUyfmewWSo
Aligning Sectors
• Many traffic accident victims died because of lacking first aid.
• Traffic policemen should be trained with first aid techniques.
• First aid stations should be set up along highways.
International experts examine Vietnam’s trafficPosted on November 26, 2012 http://talkvietnam.com/2012/11/international-experts-examine-vietnams-traffic/#.UQVR2mewWSo
Mr. Luong Ngoc KhueMinistry of Health
International Conference on Traffic Safety in Vietnam, November 23, 2012
Partners
• Husum – Village medical university• Mock – Low tech interventions• Karolinska/Bavi – Epidemiological data• Japanese – Epidemiology/GIS plotting• WHO• Red Cross• Small NGOs • Universities
Questions
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