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Emergency Trauma Care – Evidence for Impact on Survival. Junaid Abdul Razzak MD PhD FACEP Associate Professor and Chairman Department of Emergency Medicine Aga Khan University, Pakistan. Workshop for Setting Regional and National Road Traffic Causality Reduction Targets in the ESCWA Region - PowerPoint PPT Presentation
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Workshop for Setting Regional and National Road Traffic Causality Reduction Targets in the ESCWA Region
16-17June, 200916-17June, 2009 Abu Dhabi, United Arab Emirates Abu Dhabi, United Arab Emirates
Junaid Abdul Razzak MD PhD FACEPAssociate Professor and Chairman
Department of Emergency MedicineAga Khan University, Pakistan
Emergency Trauma Care – Evidence for Impact on Survival
Outline
1. Why is Trauma Care Important?
2. Trauma Center versus Trauma System
3. Evidence for Effectiveness of Trauma System in Saving Lives
4. Conclusion
WHY IS TRAUMA CARE IMPORTANT?
Issue 1
Time and Trauma DeathsPrimary
PreventionStrategies
Trauma Systems
Trauma Systems &
Rehabilitation
The Probability of Survival
MinutesMinutes
%
% S
urv
ival
Su
rviv
al
00
2020
4040
6060
8080
100100
3030 6060 9090
Survival Is Related ToSeverity and Duration
TRAUMA CARE SYSTEMIssue 2
Definitions of Terms
• “Inclusive Trauma Systems”– Not just hospitals for acute care; – Care from site to hospital to home to work
• “Regionalization”– Geographical Definitions– Based on Population
• “Public Health Approach”– Research Based; System Wide;
Multidisciplinary;
Inclusive Trauma Care System
Pre Hospital Phase
Hospital and Post Hospital Phase
Regional Trauma System
An organized and coordinated response that ensures a continuum of care at a Regional
Level Public access to the system through a uniform emergency
number Out of hospital emergency medical services (EMS) with
medical control Timely triage and transport to an appropriate level of
hospital care Reliable communication between EMS &
hospital personnel Access to trauma centers if needed Seamless transfer to rehabilitation The key to disaster care
EVIDENCE FOR EFFECTIVENESS
Issue 3
Do Trauma Centers Make a Difference?
Skamania Conference July, 1998
Journal of Trauma Sept, 1999
A symposium to evaluate the evidence regarding the effectiveness of trauma centers and systems
Skamania Symposium – Conclusions
• Evidence to date is fragmented• Largely based on preventable death
studies conducted in local areas • A few population based studies have been
conducted – using administrative data and historical controls
• Existing studies have focused on hospital mortality
• No data on VALUE !
PERCENT OF ALL SERIOUSLY INJURED (ISS PERCENT OF ALL SERIOUSLY INJURED (ISS >> 9) 9) WHO DIEWHO DIE
Pe
rce
nt o
f in
jure
d p
atie
nts
wh
o e
xpir
e
If Care Was Equally Good..If Care Was Equally Good..
Potential for saving hundreds of thousands of lives?
Change in Mortality of one in pre and post PHTLS changes the p value from 0.046 to 0.06 Ali et al. J Trauma 1997
Training for Pre-Hospital Care Providers and Mortality
The p-value become
insignificant with an increase in just
one death
Training for Pre-Hospital Care Providers and Mortality
Arisa C et. Al., 2004
Sukumaran S. et al. 2005
Preventable DeathsPreventable Deaths
Before and After San Diego Trauma System
0
5
10
15
20
1983 1985 1987 1989 1991 1993 1995 1997 1999 2000SYSTEM YEAR
Trauma System began in 1984
Non-PreventPreventable
Implementation ofTrauma System1984
2009
Crash Mortality Rate RatioPre/post Trauma System Implementation
.5 .6 .7 .8 .9 1 1.1 1.2 1.3 1.4 1.5 1.6
All
WestVirginia Washington Virginia Utah Tennessee SouthCarolina Pennsylvania Oregon NorthCarolina NewYork NewMexico NewJersey Nevada Missouri Massachusetts Illinois Georgia Florida D.C. Connecticut California
Mortality rate ratio Nathens et al
After adjusting for change in traffic safety laws, mortality was reduced by 8% across 21 states
Mortality Rate Ratio As A Function Of Time From First Trauma Center Designation
Years since trauma center designation
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
.8
.85
.9
.95
1
1.05
Mo
rta
lity
rate
ra
tio
Nathens et al
Benefits of regionalization were not seen until 10-15 years after trauma center designation
Risk of Dying: 25% Lower in Trauma Centers25% Lower in Trauma Centers!!
0
5
10
15
InHospital
30 days 90 days 365 daysTCs
NTCs
NEJM 2006;354:366-78
Overall risk of death is 25% lower in trauma centers compared to non trauma centers
Effect Larger for Young Adults . . . but Little Effect Among Older Adults
Risk of Dying in
TC vs. NTC
Ages < 55 39% lower
Ages >=55 8% lower
NEJM 2006;354:366-78
Trauma Center Care is More Costly !
Mean One Year Costs Per Patient
in thousands $2005
(adjusted for patient mix)Trauma Centers
Non-Trauma Centers
All Patients $80 $58
Moderately Severe $65 $45
Severe $94 $66
Very Severe $122 $99
MacKenzie, Jurkovich, Rivara et al, 2009
WHAT DOES IT ALL MEAN?Issue 4
Trauma SystemsTrauma SystemsNOT JUSTNOT JUST
Trauma CentersTrauma Centers
Across the continuum of careAcross the continuum of careRight patient – Right hospital – Right timeRight patient – Right hospital – Right time
• Pre-hospital• Triage• Coordination (Security)• Communication• Transportation• Rehab
Conclusion I
CONCLUSION - IICONCLUSION - II
A SUCCESSFUL TRAUMA CARE SYSTEM IS DEFINED BY:
1. Inclusiveness
2. Regionalization of Services
3. Organizational framework based on Public Health Model
4. System focused on Education, Research, Data/Trauma Registry, Prevention
CONCLUSION - III
Current Evidence Shows that in HICs Trauma System can:– Reduce the trauma related mortality by atleast
8%;– Such reduction is seen over time and it may
take upto 10 years to show its effectiveness
Thank You