Trauma and emergency research center 2 Trauma system Farzad Panahi MD Associate Professor of General...

Trauma and emergency research center 2

Trauma system

Farzad Panahi MD Associate Professor of

General SurgeryTrauma & Emergency Research

Center


Definition of trauma

• Trauma is tissue damage caused by the transfer of energy to the body above or below the tolerance of human tissue


Injury in Iran

• 153 people(1/5) die as a result of trauma daily

• 4000 “years of life lost”(1/3)due to trauma daily


The Injury Pyramid

EPISODES OF INJURIES REPORTED

EMERGENCY DEPARTMENT VISTS

40%

HOSPITAL DISCHARGES

DEATHS


Cost of Injuries

–Direct Costs

–Indirect Costs


Myth: Injuries are Accidents

• Injuries are no accident





Main concept

• Trauma is a disease that can be prevented or its negative impacts decreased, or both, by primary, secondary, or tertiary prevention efforts.


The Injury Triangle

ENVIRONMENTAGENT

HOST

VECTOR


Concepts of Injury Control

• Haddon’s Matrix

Pre-Injury Injury Post-InjuryHostAgentEnvironment


THE THREE PHASES OF INJURY PREVENTION

• PRIMARY PREVENTION: PRE-INJURY

• SECONDARY PREVENTION: AT THE TIME OF INJURY

• TERTIARY PREVENTION: POST-INJURY

Department of Emergency Medicine 13

TRAUMA SYSTEMS AND INJURY PREVENTION

• Historically, trauma centers focused on tertiary prevention.

• The trauma system, in contrast, should contribute to reducing the entire burden of injury.

• Therefore, it should integrate all three phases of injury prevention into planning and practice.


Definition

• A trauma system is a pre-planned, comprehensive, and coordinated statewide and local injury response network that includes all facilities with the capability to care for the injured.


HISTORICAL DEVELOPMENTS

• 1775: the guide for surgeons during the Revolutionary War by Dr John Jones

• 1797: Napoleon’s chief physician implements a prehospital system designed to triage and transport the injured from the field to aid stations.

• 1865: Civilian ambulance services begin in Cincinnati and New York.



• 1915: First known air medical transport occurs during the retreat of the Serbian Army from Albania.

• 1925: Dr. Lorenz Böhler forms the first trauma care system for civilians in Austria.

• 1950: During the Korean Conflict, air ambulances and forward surgical hospitals are used to reduce the time from injury to definitive surgical care.



• 1966: The National Research Council of the National Academy of Sciences publishes Accidental Death and Disability: The Neglected Disease of Modern Society.

• 1980: The ACS creates Advanced Trauma Life Support.

• 1990: US Congress passes the Trauma Systems Planning and Development


Trauma Care

The system encompasses a continuum of care


The goals of a trauma care system

• decreasing the incidence and severity of trauma• ensuring optimal care for all • preventing unnecessary deaths and disabilities • containing costs while enhancing efficiency• implementing quality and performance

improvement of trauma care throughout the system

• ensuring certain designated facilities have appropriate resources to meet the needs of the injured


A mature trauma system seeks to minimize quality of care variations

An effective trauma system comprises both patient care and social components


THE PUBLIC HEALTH SYSTEM

• The primary strategy :

– Identify a problem based on data (Assessment)

– Devise and implement an intervention (Policy Development)

– Evaluate the outcome (Assurance)


Trauma system and disaster

• Those States with the most developed trauma systems were most ready to respond to mass casualty incidents.

2002, HRSA : the National Assessment of State Trauma System Development, Emergency Medical Services Resources, and Disaster Readiness for Mass Casualty Events.


SYSTEM FINANCE

• Trauma care is lifesaving, yet expensive.

• The investment in systems can be cost-effective in terms of long-term health care costs and productivity.


SYSTEM FINANCE

• Motor vehicle fees, fines, and penalties

• Court fees, fines, and penalties (not motor vehicle related)

• 9-1-1 system surcharges

• Intoxication offense fees

• Controlled substance act or weapons violation fees

• Taxes on sales of tobacco


OUTCOMES OF TRAUMA CARE SYSTEMS

Does the establishment of trauma systems increase trauma patients'

survival?


• preventable deaths to range as high as 20–40 percent of deaths due to injury Trunkey and Lewis, 1991

• the implementation of a regional trauma system, the proportion of preventable fatalities fell from 13.6 to 2.7 percent. Shackford et al.,1986


Trauma Center Categorization


Level I Trauma Center

• Admission of at least 1,200 trauma patients yearly. • 20 % ISS >15• dedicated trauma program, trauma service, trauma

team, and medical director. • Departments of surgery, neurosurgery, orthopedic

surgery, emergency medicine, and anesthesia. • General surgeons, anesthesiologists, and emergency

medicine specialists must be immediately available 24 hours a day.


• Every surgical subspecialty ,OB/GYN and radiology on call

• Board certification for general surgeons, emergency physicians, neurosurgeons, and orthopedic surgeons.

• Completion of ATLS for the general surgeons and emergency physicians.

• personnel and equipment pertinent to trauma in all age groups.


• 24 h OR and ICU

• Radiological services (including angiography, sonography, CT and MRI), clinical laboratory, hemodialysis, burn care, and acute spinal cord management.

• Rehabilitation services

• Performance improvement and a trauma registry

• Leaders in continuing education, trauma prevention programs, and research


Level II Trauma Center

• Similar to level I facilities. • Cardiac surgery, microvascular/replant surgery,

and acute in-house hemodialysis are not required.

• A surgeon on call 24 hours a day and present at resuscitations and operative procedures.

• OR available when needed in a timely fashion. • Emergency department and ICU


Level III Trauma Center

• 24 hour general surgical coverage. • Transfer agreements • Emergency medicine, anesthesia, orthopedics,

plastic surgery, and radiology. • 24 hour operating room and on call personnel.• Computed tomography . • Trauma registry • CME availability for physician and nursing staff


Level IV Trauma Center

• Initial evaluation, assessment and resuscitation

• Transfer

• 24 hour coverage by a physician; surgical coverage may not be available.

• Located in rural

• Continuing education and prevention programs


Paradigm Shift in Trauma Care

Old Thinking New Thinking

Trauma is a “surgical disease” Trauma is a “team” disease

Exclusive: trauma care must focus on a subset of the most seriously injured patients that are threatened by death

Inclusive: trauma care must focus on all injured patients to reduce not only death but also disability and costs to society

“Trauma Centers” save lives “Trauma Care Systems” save lives, reduce disability, and costs

Competition among hospitals for “designation”

Cooperation among hospitals to assure broad system safety net access and effective stabilization and transfer


Summary

TRAUMA CARE SYSTEM PLAN COMPONENTS


ADMINISTRATIVE COMPONENTS

– LEADERSHIP

– SYSTEM DEVELOPMENT

– LEGISLATION

– FINANCE


OPERATIONAL AND CLINICAL COMPONENTS

• PUBLIC INFORMATION AND PREVENTION

• HUMAN RESOURCES


OPERATIONAL AND CLINICAL COMPONENTS cont’

• PREHOSPITAL– COMMUNICATION– MEDICAL DIRECTION

• Off-Line and On-Line Medical Direction

– TRIAGE– TRANSPORT


OPERATIONAL AND CLINICAL COMPONENTS

• DEFINITIVE CARE

– TRAUMA CARE FACILITIES

– INTERFACILITY TRANSFER

– REHABILITATION


OPERATIONAL AND CLINICAL COMPONENTS cont’

• EVALUATION– Data Collection– Trauma System Evaluation– Trauma Center Evaluation– Research

• Trauma Care Research• Research Funding

Trauma and emergency research center 2 Trauma system Farzad Panahi MD Associate Professor of General...

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