July 2008 Proposal written by Dr.Ahmed Ali Shammah Saudi Society of Emergency Medicine King Abdullah Medical City - Makkah بسم الله الرحمن الرحيم مركزالطواري

July 2008Proposal written by

Dr.Ahmed Ali Shammah Saudi Society of Emergency Medicine

King Abdullah Medical City - Makkah

الرحيم الرحمن الله بسمبمكة والكوارث واإلصابات مركزالطواري

المكرمةMAKKAH TRAUMA CENTER


Dr.Ahmed Ali Shammah Saudi Society of Emergency Medicine

King Abdullah Medical City - Makkah

This proposal written for the establishment of a world class standard trauma center to serve Makkah region .Prepared by :Sig.

Dr.Ahmed Ali Shammah , Family Med.Con.&Ass.Pro.EMS ………………………Revised by :

Dr.Salem Jafar Bajoaifer ,Orth.Con.&Head of Dep. ………………........……Supervised by :

Dr.Khalid M Aljohani ,Em.Med.Con.&President of SSEM ………………………..Approved by :

Dr.Hatem AlOmari , GDSOP – Alnoor S.H. ……………………………… Dr.Khalid Al-Somairy , GDKAMC-Makkah …………………………….This was revised by the scientific committee of the Saudi Society of Emergency Medicine to Fulfill the Verification Criteria of ACS as a Trauma center level I .

الرحيم الرحمن الله بسمبمكة والكوارث واإلصابات مركزالطواري

المكرمةMAKKAH TRAUMA CENTER

MAKKAH TRAUMA CENTER


Dr.Ahmed Ali Shammah

Saudi Society of Emergency Medicine
















Do we need a Trauma Center/s ? Why ?

MVA/Mortality/Morbidity/Hajj Accidents…

Is Trauma a preventable disease ?

Emergency Dep. VS Trauma center .

Levels of Trauma Centers .

Verification by ACS as a Trauma center level I

Location/Manpower/Supervision

Accreditation 2008



According to King Abdul Aziz City for Science & Technology and the National Committee of Traffic Safety report in S.A. during 1428 h :

Total Number of MVA = 435,264 accidents

Total Number of injuries = 36,025 injuries

Total Number accident-related deaths = 6,358 deaths

30% of all the above took place in Makkah Region

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During 1427 h :

5,883 Deaths = 21 deaths for every 1000 accidents

16Deaths per day=2 Deaths every 3hours for the whole year

Commonest Age=18-40 years ( 59% of Deaths )

27.2% Deaths in Makkah Region

5.8% Deaths in Riyadh Region















































Hajj Census & Accidents :•The total number of death among pilgrims registered in the hospitals of MOH, during the period of 1-15/12/1427H. was 568 deaths.•The pilgrim mortality rate in the period of 1-15/12/1427H., was 23.9 deaths/ 100,000 pilgrims and this rate was 29.1 deaths /100,000 pilgrims in 1426 H.• Accidents (fractures, falls and injuries) were the main leading causes of death, constituting 50.7% of the total number of deaths .

• 1427 H : Aziziah & Gazza Burns : 2600 individuals. •1426 H : Gazza Hotel : 76 Deaths +62 injuries

& 363 Deaths in Mina .•1425 H : 200 Deaths in the Rainy Day in Mina.•1424 H : 244 Deaths in Great Aqaba Stampede.•Statement by Hajj authorities on Hajj deaths and injuriesMina, Saudi Arabia, 2nd February 2004 :Thirty-six traffic accidents took place in Muzdalifa and Mina on Saturday, in which 21 suffered minor injuries and 28 died






























Trauma centers: statistics & Numerical data:Direct Transport to Tertiary Trauma Centers versus Transfer to Lower Level Facilities: Impact on Mortality and Morbidity among Patients with Major Trauma. (transportation of severely injured patients from the scene directly to Level I trauma centers is associated with an Economic and cost-effectiveness reduction in mortality and morbidity).

Journal of Trauma-Injury Infection & Critical Care. 43(2):288-296, August 1997.

Incidence of accidents among Iranian pilgrims in hajj 2004&2005( Total Number of 899 injuries = Rate of 299 per 10,000 pilgrims in 2004 &

1671 injuries = Rate of 221 per 10,000 pilgrims in 2005 ).

Saudi Med J 2006;Vol.27(7) 1053

Injured patients have lower mortality (up to 50%) when treated in Trauma Centers .Trauma M J 2006 Aug;61(2):272-8;Discussion 278-9

Reduced Mortality at a Community Hospital Trauma Center The Impact of Changing Trauma Level Designation From II to IThe significant reduction in mortality of trauma patients with severe or specific injuries after the change to a higher trauma level designation justify direct triage

of these patients to L1 facilities, when available. Arch Surg. 2008;143(1):22-27.




























Trauma centers: statistics & Numerical data:Outcome of hospitalized injured patients after institution of a trauma system in an urban area.(there was a significant reduction in the death rate) JAMA. ;271 (24):1919-24 8201736 (P,S,E,B) Cited:3

An analysis of the association of trauma centers with per capita hospitalizations and death rates from injury. (a trauma center and advanced life support training were associated with a decrease in trauma death rates). Ann Surg. 1993 Oct ;218 (4):512-21; discussion 521-4 8215642

Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. (significant decrease in hospital days

dramatically reduce the substantial financial resources ) J Trauma. 2004 Mar ;56 (3):492-9; discussion 499-500

Effect of trauma system maturation on mortality rates in patients with blunt injuries in New York State. (Improved outcomes for patients with blunt trauma can occur early in the implementation of a trauma system attributable to changes in field triage and early transport to trauma centers.)

J Trauma. 2000 Jul;49(1):63-9; discussion 69-70.























































Almost all Americans feel it is extremely or very important to be treated at a trauma center in the event of a life-threatening injury (after hearing a description of a trauma center).

Q605 If you or a family member had a serious of life-threatening injury, how important would it be to be treated in a trauma center? Base: All respondents (N=1000)

63%

31%

5%1%

Extremelyimportant

Veryimportant

Somewhatimportant

Not veryimportant

Not at allimportant

% indicating how important it would be to be treated at a trauma center if they or a family member had a serious or life-threatening injury:

94%




























About nine in ten Americans think it is extremely or very important for an ambulance to take them to a trauma center in the event of a life-threatening Injury, even if it is not the closest hospital.

Q610 If you or a family member had a serious of life-threatening injury, how important would it be to be that an ambulance be instructed to take you to a trauma center able to handle your specific injury, even if it is not the closest hospital? Base: All respondents (N=1000)

54%

33%

9%2% 1%

Extremelyimportant

Veryimportant

Somewhatimportant

Not veryimportant

Not at allimportant

% indicating how important it would be taken by ambulance to a trauma center even if it were not the closest hospital:

87%




























Nine in ten Americans feel that having a trauma center nearby is equally or more important than having a library.

Q617 Is having a trauma center within easy reach of where you live more important, equally important, or less important that having a public library? Base: All respondents (N=1000)

71%

18%

10%

More Important Equally important Less important

% indicating that compared to a having a public library, a trauma system is …:

89%




























Nearly eight in ten Americans would be willing to pay a dime or more per year to have trauma centers and systems in their state. Over half would be willing to pay $25 or more.

12%

3%7% 7% 6%

28% 27%

Would notbe willing to

payanything

A dime $1 $5 $10 $25 $25+

Q735 How much would you be willing to pay per year to have trauma centers and a trauma system in your state ready to provide care to you and your family if you were seriously injured? Base: All respondents (N=1000)

% indicating how much they would be willing to pay per year to have trauma centers and a trauma system in their state ready to provide care if they or their

families were seriously injured:

55%

78%

Sunset….

or

……..Sunrise
























The emergency department (ED), (ER), (EW),(A&E) :is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and requiring immediate attention.

Many hospitals have a separate area for evaluation of psychiatric problems with at least one room for people who are actively a risk to themselves or others (e.g. suicidal).Emergency departments may also have a separately streamed service for minor and rapidly treatable conditions, such as minor injuries.

The fast track allows for quicker treatment of patients who may otherwise be forced to wait for more pressing cases to resolve. This part of the department may be called by several names e.g. Urgent Care Centre, Fast Track Unit or Primary Care Suite depending on the local emphasis. Where this type of service is provided on a separate site from the local ED it is called a Minor Injuries Unit or an Urgent Care Clinic.




http://en.wikipedia.org/wiki/Medical_emergency

http://en.wikipedia.org/wiki/Mental_illness

http://en.wikipedia.org/wiki/Suicide

http://en.wikipedia.org/wiki/Minor_Injuries_Unit

Trauma Center Designation

Level IRegional Trauma Center

All types of surgical and medical subspecialtyResearch and teaching commitment

Level IIArea Trauma Center

Majority of surgical and medical subspecialties available 24/7Level III

Community Trauma CenterSpecialized ED with the majority of surgical and medical subspecialties available 24/7 (on call)

Level IVRural community hospitals

No immediate surgical intervention necessaryStabilize and transfer out













The emergency department (ED), (ER), (EW),(A&E) :A typical emergency department has several different areas, each specialized for patients with particular severities or types of illness.In the triage area, patients are seen by a triage nurse who completes a preliminary evaluation, before transferring care to another area of the ED or a different department in the hospital. Patients with life or limb-threatening conditions may bypass triage and be seen directly by a physician.The resuscitation area is a key area of an emergency department. It usually contains several individual resuscitation bays, usually with one specially equipped for pediatric resuscitation. Each bay is equipped with a defibrillator, airway equipment, oxygen, intravenous lines and fluids, and emergency drugs. Resuscitation areas also have ECG machines, and often limited X-ray facilities to perform chest and pelvis films. Other equipment may include non-invasive ventilation (NIV) and portable ultrasound devices.

http://en.wikipedia.org/wiki/Paediatrics

http://en.wikipedia.org/wiki/Defibrillator

http://en.wikipedia.org/wiki/Oxygen_therapy

http://en.wikipedia.org/wiki/Intravenous_therapy

http://en.wikipedia.org/wiki/Electrocardiogram

http://en.wikipedia.org/wiki/X-ray

http://en.wikipedia.org/wiki/Mechanical_ventilation#Positive_and_negative_pressure_ventilation

http://en.wikipedia.org/wiki/Medical_ultrasonography





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The emergency department (ED), (ER), (EW),(A&E) :The majors, or general medical, area is for stable patients who still need to be confined to bed. This area is often very busy, filled with many patients with a wide range of medical and surgical problems. Many will require further investigation and possible admission. Patients who are not in need of immediate treatment are sent to the minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing.

A paediatric area for the treatment of children has recently become standard, to dedicate separate waiting areas and facilities for children. Some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures.Very few EDs have a dedicated area for obstetrics nowadays. In most cases, a pregnant woman who presents to the ED is sent immediately to the obstetrics/maternity ward or the Labour and Delivery suite, unless she has another medical condition that requires treatment first.

http://en.wikipedia.org/wiki/Fracture_%28bone%29

http://en.wikipedia.org/wiki/Dislocation_%28medicine%29

http://en.wikipedia.org/wiki/Wound

http://en.wikipedia.org/wiki/Suture

http://en.wikipedia.org/wiki/Paediatric

http://en.wikipedia.org/wiki/Anxiety

http://en.wikipedia.org/wiki/Obstetrics
























When Do Trauma Patients Die?When Do Trauma Patients Die?





05

101520253035404550

Immediate Early Late

Severe Head or CV Injury

% of Deaths

Major Torso or Head Injury

Infection and MSOF





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A trauma center is a hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries 24 hours a day, 365 days per year.

Trauma centers were established as the medical establishment realized that such injuries often require immediate and complex treatment, including surgery, to save the patient.

In order to qualify as a trauma center, a hospital must have a number of facilities, including a high-quality intensive-care ward and an operating room staffed around the clock.

A trauma service is led by a team of trauma surgeons, including such specialists such as neurosurgeons and orthopedic surgeons.The operation of a trauma center is extremely expensive.As there is no way to schedule emergency services, the traffic of a trauma center can vary widely. Different methods have been developed for dealing with this. A trauma center will often have a helipad for receiving patients that are airlifted to the hospital. In many cases, persons injured in remote areas and brought to a trauma center by helicopter can receive faster and better care than a person injured in a city and taken to a hospital by ground ambulance

http://en.wikipedia.org/wiki/Hospital

http://en.wikipedia.org/wiki/Emergency_medical_service

http://en.wikipedia.org/wiki/Physical_trauma

http://en.wikipedia.org/wiki/Surgery

http://en.wikipedia.org/wiki/Trauma_surgeon

http://en.wikipedia.org/wiki/Neurosurgery

http://en.wikipedia.org/wiki/Orthopedic_surgery

http://en.wikipedia.org/wiki/Helipad

http://en.wikipedia.org/wiki/Helicopter

http://en.wikipedia.org/wiki/Ambulance





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Definitions in the United States :In the United States, trauma centers are ranked by the American College of Surgeons (ACS),

from level I : (comprehensive service)

to level III : (limited-care).

The different levels refer to the kinds of resources available in a trauma center and the number of patients admitted yearly.

These are categories that define national standards for trauma care in hospitals. Level I and level II assignments are also given adult and or pediatric designations.

Additionally, some states have their own trauma center rankings separate from the ACS. These levels may range from level I to level IV.

http://en.wikipedia.org/wiki/United_States

http://en.wikipedia.org/wiki/American_College_of_Surgeons

http://en.wikipedia.org/wiki/Adult

http://en.wikipedia.org/wiki/Pediatric





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Level I :A level I trauma center provides the highest level of surgical care to trauma patients. It has a full range of specialists and equipment available 24 hours a day and admits a minimum required annual volume of severely injured patients. A level I trauma center is required to have a certain number of surgeons and anesthesiologists on duty 24 hours a day at the hospital, an education program, preventive and outreach programs. Key elements include 24-hour in-house coverage by general surgeons and prompt availability of care in varying specialties such as orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, oral and maxillofacial surgery, and critical care, which are needed to adequately respond and care for various forms of trauma that a patient may suffer.

Additionally, a Level I center has a program of research, is a leader in trauma education and injury prevention, and is a referral resource for communities in nearby regions.

http://en.wikipedia.org/wiki/Physical_trauma

http://en.wikipedia.org/wiki/Surgery





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Trauma Care System

Integration ofEMSHospital care

ReducesCostTime to surgeryMortality

Proper CareImmediate surgical intervention to repair hemorrhage sites

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Level II :A level II trauma center works in collaboration with a Level I center. It provides comprehensive trauma care and supplements the clinical expertise of a level I institution. It provides 24-hour availability of all essential specialties, personnel, and equipment.

Minimum volume requirements may depend on local conditions. These institutions are not required to have an ongoing program of research or a surgical residency program.

Level III :A level III trauma center does not have the full availability of specialists, but does have resources for emergency resuscitation, surgery, and intensive care of most trauma patients.

A level III center has transfer agreements with level I or level II trauma centers that provide back-up resources for the care of exceptionally severe injuries.

Trauma Care System :• Integration of

– EMS– Hospital care

• Reduces– Cost– Time to surgery– Mortality

• Proper Care– Immediate surgical intervention to repair

hemorrhage sites





Trauma Center Designation :• Level I

– Regional Trauma Center– All types of surgical and medical subspecialty– Research and teaching commitment

• Level II– Area Trauma Center– Majority of surgical and medical subspecialties available 24/7

• Level III– Community Trauma Center– Specialized ED with the majority of surgical and medical

subspecialties available 24/7 (on call)

• Level IV– Rural community hospitals – No immediate surgical intervention necessary– Stabilize and transfer out





























Differences between Level I and II Trauma Centers :• Level I:

– 1,200 trauma admissions/year

– Pts w/ ISS >15 (240 total or 35 pts/surgeon)

– Immediate surgical capability available

– In-house trauma surgeon

– General surgery residency program or trauma fellowship

– Research

• Level II:– No minimum

patient criteria– Surgical capability

available in a “reasonably acceptable time”

– General surgeon present at resuscitation

– Desirable to have residents

– No research minimum


• Level I– Regional Trauma Center– All types of surgical and medical subspecialty– Research and teaching commitment

• Level II– Area Trauma Center– Majority of surgical and medical subspecialties

available 24/7• Level III

– Community Trauma Center– Specialized ED with the majority of surgical and

medical subspecialties available 24/7 (on call) • Level IV

– Rural community hospitals – No immediate surgical intervention necessary– Stabilize and transfer out













Trauma Center Designation :• Specialty Centers :

– Neurocenters– Burn Centers– Pediatric Trauma– Hyperbaric Medicine– Microsurgery














Role of EMS :

• Trauma Triage Criteria– START– Nearest appropriate facility

• Mechanism of Injury Analysis (MOI)– Processes and forces that cause trauma– Consider inertial forces

• Index of Suspicion (IOS)– Anticipation of injury to a body region, organ,

or structure based on MOI– Shock and head injury– Frequent reassessment and trending




















• The Golden Hour :– Research has shown that the BEST

survivability from incident to surgery is 1 hour. (The shorter time, the better!)

– Platinum 10 Minutes• Scene time limited to 10 minutes

– Air Transport• Speed vs. need• Type of patients transported

Role of EMS :




















• Decision to Transport :– Based upon trauma triage criteria

• Critical Problems– IV Access and other time-consuming procedures

en route

• Err on the side of precaution

– If patient DOES NOT fit a trauma triage criteria but has signs and symptoms, RE-EVALUATE!




















• Injury Prevention :– National Traffic Safety– Firearm safety– Boat safety– Environmental changes

• Data,Trauma Registry & Research :– Data retrieval system for trauma

patient information– Used to evaluate and improve the

trauma system






















































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Mission, Vision, and MandateMission :A multidisciplinary clinical, educational and research institution dedicated to world class standards in the prevention and management of critical injury and illness and its consequences.

Vision :A Trauma & Critical Care Resource Global Innovator in Critical Illness, Injury & Trauma Systems Development•Clinical Excellence •Advanced Medical Research & Education •Organizational Excellence •Health Care Policy & Reform World Class Trauma and Critical Care Standards: Patient Care, Science & Leadership

Mandate :“Makkah Trauma Center will be the core element of the region emergency medical system and shall work to serve as the best trauma clinical resource center."




























Clinical Services :•Emergentologist 10•Orthopedic Traumatology 8•Trauma Neurosurgery 6•Trauma Critical Care Medicine 12•Trauma Surgery 12•Trauma Ophthalmology 4•Trauma Otolaryngology-Head and Neck Surgery 6•Trauma Plastic Surgery 6•Trauma Radiology 6•Wound Healing 6•Hyperbaric Medicine 3•Infectious Diseases 3•Oral and Maxillofacial Surgery 4•Trauma Anesthesiology 12•Nurse Practitioner Trauma Specialty Group 26• Patient Care Services : 48 (Nursing, Rehabilitation Services, Respiratory Therapy)




























Location of Makkah Trauma Center:KAMC Vs. Mina EMS(Advantages/Disadvantages)Experts Opinions




























Makkah Trauma Center :Operation & Maintaining a Level I Trauma Center :




























Makkah Trauma Center :

Attached is a 90 pages including all the Detailed 2008 Standards for Trauma CenterAccreditation levels I,II,III… and the Scientific Committee of Saudi Society of Emergency Medicine (SSEM) is very welling to supervise and help you implementing this for a Level I Makkah Trauma Center .

Documents

July 2008 Proposal written by Dr.Ahmed Ali Shammah Saudi Society of Emergency Medicine King Abdullah Medical City - Makkah بسم الله الرحمن الرحيم مركزالطواري