REPORT ON TRAUMA CENTRE SIRSA BY DR JAIDEEP MPH

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REPORT ON TRAUMA CENTER SIRSA BY- DR.JAIDEEP KUMAR MPH ON

8/8/2009

What is Trauma?

The word ‘trauma’ is derived from the Greek meaning ‘bodily injury’.

What is Trauma Centre?

Trauma centre is defined as a specialised hospital facility distinguished by the immediate

availability of specialised surgeons, physician specialists, anesthesiologists, nurses, and

resuscitation and life support equipment on a 24-hour basis to care for severely injured

patients or those at risk for severe injury.

Magnitude of Trauma and Injuries:-

Incidence of trauma is on the rise globally due to industrialization, urbanisation,

increase in mechanised transport, urban violence, social conflicts, and man-made as well

as natural disasters. Trauma is a number one killer below 40 years leading to high

morbidity, mortality, disability and economic loss to the country.If current trend

continues, road traffic injuries intentional injuries i.e. self inflicted injuries, interpersonal

violence and war related injuries will rank among the 15 leading causes of death and

burden of disease. Road traffic injuries are a leading cause of death by injury accounting

for 20.3 per cent of all deaths from injury.

It is 10th leading cause of all deaths, ninth leading contributor to the burden of disease

worldwide. Deaths from injuries are projected to rise from 5.1 million at present to 8.4

million by 2020. In India, 80, 000 persons got killed and 38 million persons got injured

due to road traffic accidents. In Armed Forces, approximately 20 persons per 1000

population get admitted in the hospitals due to non-enemy action injuries per year. India

has 1% of the motor vehicles in the world, but bears the burden of 6% of the global

vehicular accidents. Road-traffic accidents are increasing at an alarming annual rate of

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3%. In 1997, 10.1% of all deaths in India were due to accidents and injuries. A vehicular

accident is reported every 3 minutes and a death every 10 minutes on Indian roads.

During 1998, nearly 80,000 lives were lost and 330,000 people were injured. Of these,

78% were men in age group of 20-44 years, causing significant impact on productivity.

A trauma-related death occurs in India every 1.9 minutes. The majority of fatal road-

traffic accident victims are pedestrians, two wheeler riders and bicyclists.

India is a disaster-prone country with frequent floods, cyclones, landslides and

earthquakes. Train accidents and industrial mishaps are not uncommon. Government

plans are in place, in general, to deal with disasters. However, regular drills to test

preparedness are not carried out. Only 26% of the systems in the survey reported a well-

documented disaster management plan. The rest of the systems have plans under

development, or no plans. This deficiency has resulted in excessive numbers of deaths in

natural disasters. In 1999, there was an increase of 20.8% in fatalities due to such

disasters compared to the previous year. This figure for 2001 is likely to rise even further

as a result of a killer earthquake in Gujarat, causing over 12,000 deaths.

Why Trauma centre was developed?

It is established that the mortality in serious injuries is six times worse in a developing

country such as India compared to a developed country. The future appears both daunting

and challenging. It is estimated that from its present position of the ninth leading cause of

deaths in India, trauma will move up to third position by 2020. It is also estimated that in

the developing countries over 6 million will die and 60 million will be injured, or

disabled, in the next 10 years. India will have a large share in this, with an estimated

economic loss of around 2% of GDP. To meet this challenge several efforts are required:

resource creation, education, legislation, upgrading prehospital and hospital based care,

public awareness and a change in the attitude of the policy-makers. The public health

institutions will also benefit from adopting WHO Essential Trauma Care guidelines for

trauma care, which is aimed at low cost improvements to the trauma care. There are

already some ongoing efforts in that direction.. Rapid urbanisation and industrialisation

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have created an environment in which humans are continuously exposed to myriad

hazards. An accident is rarely caused by a single factor rather a series of events coincide

in time and space for the unfortunate event to occur. Last decade has witnessed a

considerable increase in morbidity and mortality from the road accidents. Trauma is the

third major cause of death amongst all possible reasons after heart ailments and chest

infections. Most of the serious injuries resulting from traffic accidents are related to head,

spine at internal vital organs. In accidents 50% of the victims have serious injuries to

cardiovascular or central nervous system and die in the first 15 minutes.Of the rest ,basic

life support,first –aid and replacement of fluid,if arranged within the first hours of injury

(golden hour) can save many lives. 35% die within next 1-2 hours due to head and chest

injuries and over 15% die over a next 30 days due to sepsis and vital organs failures. The

time between injury and initial stabilization is the most critical period for the patient

servival.Among trauma patient treated through conventional emergency services the

preventable death ranges up to 17%.The pre hospital trauma care plays great role in this,

so we must emphasis on this area.

Thus the time between injury and initial stabilisation which ranges between 30 to 60

minutes is most critical period for patient's survival. Stabilisation of general condition of

accident victims coupled with early treatment can shorten the period of recovery. Delay

on this account may result in death and permanent disability. The lessons learned in

successive military conflicts have advanced our knowledge of care of the injured patient.

Wars established the importance of minimising time from injury to definitive care. The

extension of this concept to the management of civilian trauma led to the evolution of

today's trauma systems.

A trauma centre equipped with necessary modern gadgets, appliances and trained

manpower can increase the patients' survival and full recovery.

Planning parameters for trauma centre :-

1. Location: It should be located on ground floor and should have direct access from main

road. A separate approach, other than the OPD with a spacious parking area for cars and

two-wheelers is required. It should be located adjacent to the OPD to share the resources

such as diagnostics and also pool resources in case of a disaster.

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It should be well lighted and boldly signposted both for day and night, direction signs

should be put on the main traffic routes passing through the station (If happens to be the

only trauma service in the station). Drive through and covered ambulance post should be

capable of accommodating at least two ambulances.

Helipad is required for major trauma centres and in rural, hilly, or unapproachable areas.

Good and well maintained lawn with fixed benches and seasonal flowers serves as an

additional waiting area for relatives.

2. Inter-relationship: A trauma centre should have close inter-relationship with operation

theatre, radiology, blood bank, laboratory, ICU, obstetrics, records, OPD and mortuary.

Some authorities recommend close relationship with CCU as well. Many sub departments

are required in trauma centre itself i.e. OT, diagnostics etc.

3. Work & traffic flow: Efficiency of any busy and high intensity department like trauma

centre can be greatly increased by smooth and orderly flow of traffic for

(a) Patient

(b) Staff

(c) Supplies

Internal traffic flow should aim at maximising efficiency at all times. All modalities of

communication be employed to save time such as telephone, intercom etc.

4. Entrance: Entrance should be separate from main hospital's entrance and separate for

ambulant and stretcher bound patients which includes a ramp. Doors of entrance should

be 2.4 metre wide, 2-way with glass panel at eye height and spring to keep them in open

position and they should open into the reception area. Automatic sliding doors also can

be used to prevent accidents in case of swinging doors. The entrance to registration

should be at a close distance.

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5. Reception area: Entrance should open into a large open space with reception desk in

front. Trolley, stretcher, and wheelchair parking area as well as a facility for cleaning

stained trolleys are a must. Waiting room for patients and relatives, police desk room,

room for drivers, space for medico-social worker, cafeteria, toilets, registration and

records, security, cash counter, and telephone booth should open into reception.

Other areas recommended are puja room, grief room, flower, chemist, and bookshop.

Size of reception area depends on patient load, (0.75 sqm per patient for 1/3rd of

attending population in waiting area). BIS recommends 1.75 sqm per hospital bed for

reception area.

6. Waiting area: Waiting area is required for ambulant patients and accompanying family

members. It is also for preventing people from entering clinical areas and can be used as

triage area in case of disaster. It should be visible from reception desk. Provisions for

reading material and wall posters regarding health as well as for public relation activity

and facilities such as drinking water, ladies and gents toilets, television and channel

music are a must in these areas.

7. Examination and treatment area: Main area of trauma department. Going as per patient

flow, the various rooms/ areas in this area are:

(a) Triage area.

Separate area or lobby may be used.

(b) Nurses and surgeon's station.

It should be near entrance and registration area, with multiple communication modes,

may be glass enclosed above counter level, with a private toilet. It should have work area

with lockers, refrigerators, counter sink, a small flash steriliser, IV fluids and medicine

storage.

Other features are dispensing/storage cabinets, ample counter and drawer space, CC

monitoring, TV for surveillance of holding and treatment areas, bulletin boards, racks for

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references and manuals, and storage area for supplies. It should have easy approach to

clean and dirty utility area.

(c) Examination and main treatment area.

The importance of this area is 'Urgency in diagnosis and treatment' and not any social

consideration. It should be large, unobstructed, well-illuminated space for moving heavy

equipment, stretchers, and team of health care providers. 11.5 X 11.5 metre for an open

trauma treatment room is recommended for access to patient from all sides.

Treatment spaces/cubicles can be partitioned by curtains or semi-permanent booths.

Where cubicles are planned they should be 3.3 X 4.5 metre in size. Doors should be at

least 1.6 metre wide.

8. Resuscitation room: Thirty sq metre room required for stabilisation of injured or

acutely ill patients who need care of Airway, Breathing and Bleeding, and Circulation

(ABC). It is an equipment intensive area, requiring both diagnostic and therapeutic

equipment such as patient's trolley, piped oxygen and suction, adjustable lamps,

cupboards, washbasin, worktops, as well as equipment for minor surgeries.

All shelves and drawers must be clearly labelled. It should be connected to emergency

electrical supply and from here patient will be moved either to intensive care area,

operation theatre, recovery room, treatment room, or transported to a nursing unit.

9. Operation room: It is required for ease in urgent surgery. There is no requirement of

transferring contaminated cases to main OT complex, and schedule of normal OT is not

disturbed by emergency cases.

It is preferable to have one room for clean operations and one for septic/contaminated

cases. The latter can also be used for plaster room, both of these must provide enough

space for staff, instrument trolley, mobile X-ray apparatus, and storage.

10. Other areas required in trauma centre

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(a) Plaster room: It should have provision for orthopaedic and cast work. It should

include storage for splints and orthopaedics supplies, traction hooks, X-ray film

illuminators and examination lights, plaster trap is a must in the sink.

(b) Surgical ICU minimum of eight beds for a centre handling 1200 cases per annum with

attendant facilities, well staffed and equipped trauma ward as a step down facility.

(c) Radiology: Seventy five per cent of trauma patients will require radiographic

investigations. This dept may become a bottleneck in smooth flow if not managed

properly. Size and facility will depend on relation and distance from main radiology

department unless latter is just adjacent, otherwise a satellite X-ray unit is definitely

required.

A large X-ray room may be divided by partition into two or three bays, each large enough

to carry out an examination of patient on stretcher, besides mandatory mobile unit. It is

recommended to have a static 300/500 mA unit dedicated to a large trauma department.

CT scan unit for a large trauma centre and dedicated USG facility.

(d) Laboratory: Type and size of laboratory will depend on relation with main hospital

laboratory. An emergency facility capable of performing routine blood and urine

analysis, bacterial smears and stains definitely is required. Advanced tests such as BGA,

and biochemistry may be done in main laboratory.

(e) ECG, blood bank: Closely related to or easy access to a blood bank recommended.

(f) Duty room for doctors and nurses: A nine sqm room each with bed, chair, desk,

bookshelf, TV, telephone, lockers, toilet and shower required.

(e) Storage area: Area/alcove for mobile equipment such as mobile X-ray, crash cart,

ventilators, and area for storing mobile furniture, clean instruments and linen, drugs, IV

fluids, and dirty utility.

(g) Janitor's closet: With a designated space for waste disposal containers.

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(h) Administrative areas: Offices for director and matron are required. Conference hall is

required in a teaching institute, preferably with a reference library. Pantry of seven sqm

for providing hot and cold fluid/beverages round the clock for staff is necessary. Disaster

area 90 sqm with lighted open space, close to the entrance, with little fixed furniture and

adequate storage spaces.

(j) Communication room: Two way radio communication with ambulances,

intercommunication between hospitals, intramural communication in the form of check-

in board, PA system, telephone (including hotline), intercom, computer network and

dumb waiters for supplies are now a days required in such a modern centre.

11. Hospital organisation: Level I centre must have the following staff: -

(a) A dedicated trauma medical director who could preferably be a surgeon

(b) Trauma team:

(i) General surgeon

(ii) Emergency physician

(iii) Surgical and emergency residents

(iv) Nurses

(v) Laboratory technician

(vi) Radiology technician

(vii) Anesthesiologist

(viii) Security officers

(ix) Social workers

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12. Training of staff: Training of staff is of utmost importance to run an efficient trauma

centre. Training is a continuous process as staff keeps on changing in a large hospital.

They should not only be highly proficient in own trade but should also be trained in good

human relationship as well.

The acute distress, anxiety and urgency on part of patient and relatives should be matched

by calm, alert and reassuring attitude of staff. Human relations and human attitudes are

consistently put to a very severe test and success depends largely on reputation of

hospital and confidence of community in its service.

13. Ambulance services: An efficient ambulance service is a must for the success of

trauma system. The ambulance has been defined by the committee on ambulance design

criteria, US, as a vehicle for emergency care which provides a driver compartment and a

patient compartment which can accommodate two emergency medical technicians and

two lying patients so positioned that at least one patient can be given intensive life

support during transit.

Two way radio communication for safeguarding personnel and patient's under hazardous

condition and light rescue procedures. It is designed and constructed to afford maximum

safety and comfort. It avoids aggravation of the patient's condition, exposure to

complication and threat to survival.

14. Essential requirements for a well organised trauma centre:

(a) Trauma centre should be readily accessible to afford quick transfer of patient from

ambulance to bed or operating table.

(b) Efficient , promptly responding, well equipped ambulance service with competent

personnel in charge.

(c) Well equipped, trauma operating room with supplies always ready for use.

(d) Recovery room where patient can be sent after emergency treatment.

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(e) Efficient hospital personnel always on duty or on call which should include at least a

competent surgeon, nurse, and an attendant or orderly.

(f) Supervision of treatment of fractures by a well qualified orthopaedic surgeon, and

supervision of the care of other injuries by those who are competent in their respective

fields.

(g) Adequate diagnostic and therapeutic facilities under competent medical supervision.

(h) Complete medical record of all patients treated which includes particularly immediate

record of injury and a detailed description of physical findings, treatment and results.

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Sirsa district has an area of 4,276 sq km and its population is 9,03,000. The district

headquarter is situated in Sirsa town. It is 255 km from Delhi and 280 km from

Chandigarh. Other smaller towns are Dabwali, Ellenabad, Rori and Rania. The district

lies between 29 14 and 30 0 north latitude and 74 29 and 75 18 east longitudes, forming

the extreme west corner of Haryana. It is bounded by the districts of Faridkot and

Bhatinda of Punjab in the north and north east, district Ganganagar and hanumangarh of

Rajasthan in the west and south and Hissar and Fatehbad district in the east.Sirsa district

is divided into 3 sub-divisions and 4 tehsils. There are a total of 323 villages in the

district out of which 313 are connected with paved roads. About 79% of the population

lives in the rural areas. Sirsa gets an annual rainfall of about 26 cm. The area under

http://www.haryana-online.com/Districts/hissar.htm

http://www.haryana-online.com/rajasthan.htm

http://www.haryana-online.com/panjab.htm

http://www.haryana-online.com/

http://www.haryana-online.com/chandigarh.htm

http://www.haryana-online.com/delhi.htm

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cultivation is 3,88,000 hectares out of which 3,06,000 is irrigated. The district excels in

the production of cotton and citrus fruit.

Purpose with which Trauma centre Sirsa was opened?

Haryana State is situated in the North West part of India adjoining Delhi, Rajasthan,

Himachal Pradesh, U.P. & Punjab. Four National Highways i.e. National Highway No. 1

(Ambala-Delhi G.T. Road), No. 2 (Delhi-Jaipur Road), No. 10 (Defence Road passing

through Sirsa) and Delhi-Mathura Road pass through the State. Also the State Highway

between Chandigarh and Delhi crosses different districts of the State. National Highway

No.10(Defence Road) is passed through Sirsa.This road joins the main border army

stations like Hissar,Hanumangarh and Shri ganganagar with each other.Air-force station

of Sirsa is also situated on it.Inspite of importence in defence line,this district is

contributed in providing the health services to many adjoining areas of Panjab,Rajasthan

and Haryana.All these areas depends on Sirsa for critical care,but due to lack of

superspeciality care the patient from sirsa hospital are referred to PGI Rohtak for further

treatment. The time which is taken by the distance (App.5hours) cause many morbidity

and mortality of injured person. About 50% of the victims die in the first 15 minutes due

to brain injuries. A further 35% die within next 1-2 hours due to head and chest injuries

and over 15% die over a next 30 days due to sepsis and vital organs failures. Thus the

time between injury and initial stabilisation which ranges between 30 to 60 minutes is

most critical period for patient's survival. Stabilisation of general condition of accident

victims coupled with early treatment can shorten the period of recovery. Delay on this

account may result in death and permanent disability.BY taking the account of this

situation the State Govt. has sent a proposal amounting to Rs.5.50 crores to the Govt.

of India for setting up a Trauma centre at Sirsa vide letter No. 25/9-3PM-2000/3326

dated 14.6.2000.

Facilities proposed to be provided at Trauma Centres:-

- Fully equipped Emergency wards to provide appropriate medical and

surgical care to the accident victims.

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- Fully equipped operation theatres.

- Intensive care Units for the seriously ill.

- Neurology units for dealing with head and spine injuries

- CT Scan, Ultra-sound and round the clock X-ray facilities

- Laboratory services

- Fully equipped orthopaedic units.

- Waiting Halls for attendants of the patients

- Canteens for the patients and their attendants

MACHINERY AND EQUIPMENT

Sr. No. Item Quantity Approx. cost

1. Spiral CT 1 Rs. 2 crores

2. 800 MA X-ray Machine 1 Rs. 12 lacs

3. Portable X-ray Machine 1 Rs. 8 lacs

4. Image Intensifier (one each for OT &

Casuality)

2 Rs. 30 lacs

5. Electronic Tourniquet Kit 3 Rs. 1 lac

6. Battery operated Drill Machine with all

attachments for Jacob's Chunk reamers

2 Rs. 7 lacs

7. DHS (Dynamic with Hip Screw) 1 Rs. 4 lacs

8. DCS ( Dynamic Condylor Screw) 1 Rs. 4 lacs

9. Inter locking nail for flunners, libia, humans 1 Rs. 9 lacs

10. Basic sets for Plating (3.5m, 4.5m) 2 Rs. 6 lacs

11. Instrument set for Kuntsilmer Nailing 1 Rs. 20000

12. Instrument set for partial hip Replacement 1 Rs. 20000

13. Bone Nibblers, Amputation saw Curttes,

Plaster Saw (Electric), Bone Cutter

1 each Rs. 20000

14. Cautery Machine 3 Rs.40000

15. Orthopaedic table for OT/Casuality 2 Rs. 60000

16. OT table with radiolucent top in each OT room 1 Rs. 80000

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17. Bulken frames for beds (one for each bed) Rs. 60000

18. OT lights- ceiling/ Satellite portable OT light

in each OT

2 Rs. 40000

19. Horizontal Autoclave 2 Rs.2.60 lacs

20. Small Horizontal Autoclave (for casuality) 2 Rs. 60000

21. Centrifugal Machine 1 Rs.40000

22. Microscope Binocular 2 Rs.25000

23. Semi Autoanalyzer 1 Rs. 2.00 lacs

24. Misc. item for one year Rs.75000

25. Central Pipeline for Oxygen Rs.20 lacs

26. Boyle's Apparatus fully equipped with all

accessories atleast one per OT

Rs. 2 lacs

27. Suction Machines in OT Rs. 1 lac

28. Cardiac Monitor/Pulse Oximeter in each OT Rs. 2 lacs

29. Extension board & sufficient power points for

electricity in each wall of OT

Rs. 2 lacs

30. Ventilators for OT/ICU for prolonged IPPV

(Intermittent Positive Procure Ventilation)

Rs. 7 lacs

31. Neurological Equipment Rs.1 crore

32. Hospital Furniture Rs. 40 lacs

33. General Equipment Rs. 10 lacs

Total 4.75 crores per Trauma Centre

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OVERVIEW OF TRAUMA CENTRE, SIRSA

Trauma Centre Starts on : 12.04.08

Previously chosen area: 1200 sqm

Current area: 1264.20 sqm

Cost: 154.47lakh

1.Machinery Equipment & Instruments for Trauma Centre, District Sirsa already

supplied

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Sr. No. General articles Quantity

1 OT Table 4

2 Ceiling Lights 2

3 Portable OT Lights 1

4 Suction Machine 1

5 ICU Beds with Mattress 5

6 Revolving Stool 10

7 Microscope 1

8 Calorimeter 1

9 X- ray machine(without accessories) 500mA 1

2. STAFF POSITION OF TRAUMA CENTER, SIRSA

Sr.

No.

Name of the post Sanctioned Filled up Vacant Salary Remarks

1 Medical officer (neuro surgeon) 1 - 1 -

2 Medical Officer (neurology) 1 - 1 -

3 Medical officer (ortho) 2 1 1 -

4 Medical officer (gen. surgery) 2 - 2 -

5 Medical officer (anesthesia) 2 1 1 -

6 Medical officer (radiology) 2 - 2 -

7 Medical officer

(gen. duty)

4 - 4 -

8 Pharmacist 4 4 - 16299

+12662

+12662

+12662

=54285

-

9 Radiographer 4 4 - 12570

+11160

+11703

1 absent

from duty

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=35433

10 Nursing sisters 1 1 - 19071 -

11 Staff nurse 7 7 - 12665*7

=88655

-

12 OT Assistant 3 3 - -

13 Lab technician 4 - 4

14 Store keeper 1 - 1 -

15 Office clerk/ accountant 3 - 3 -

16 Sweeper and ward boy On

contract

3. Services provided in the trauma center (12.04.08-23.02.09)

Total

number of

patients

Treated by

Dr. Gaurav

(ortho

surgeon)

Treated by

Dr. Chauhan

(orthosurgeon)

Treated

(cured)

Referred Cause of

referral

Deaths

249 233 16 242 7 Critical

care

0

Dr.Gourve Bishnoi is on call ortho surgeon from General Hospital Sirsa

4.Annual report of trauma centre : No

5.Self assessment report of trauma centre authority: No

6.Fire safety measures :No

REPORT ON TRAUMA CENTRE SIRSA BY DR JAIDEEP MPH

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Transcript of REPORT ON TRAUMA CENTRE SIRSA BY DR JAIDEEP MPH