Transcript Slide 1

Trauma system
Farzad Panahi MD
Associate Professor of
General Surgery
Trauma & Emergency Research
Center
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Definition of trauma
• Trauma is tissue damage caused by
the transfer of energy to the body
above or below the tolerance of
human tissue
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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
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The Injury Pyramid
DEATHS
HOSPITAL
DISCHARGES
EMERGENCY DEPARTMENT VISTS
40%
EPISODES OF INJURIES REPORTED
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Cost of Injuries
–Direct Costs
–Indirect Costs
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Myth: Injuries are Accidents
• Injuries are no accident
• Injuries are no accident
• Injuries are no accident
• Injuries are no accident
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Main concept
• Trauma is a disease that can be
prevented or its negative impacts
decreased, or both, by primary,
secondary, or tertiary prevention
efforts.
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The Injury Triangle
HOST
VECTOR
AGENT
ENVIRONMENT
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Concepts of Injury Control
• Haddon’s
Matrix
Pre-Injury
Injury
Post-Injury
Host
Agent
Environment
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THE THREE PHASES OF INJURY
PREVENTION
• PRIMARY PREVENTION: PRE-INJURY
• SECONDARY PREVENTION: AT THE
TIME OF INJURY
• TERTIARY PREVENTION: POST-INJURY
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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.
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Department of Emergency Medicine
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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.
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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.
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HISTORICAL DEVELOPMENTS
• 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.
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HISTORICAL DEVELOPMENTS
• 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
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Trauma Care
The system encompasses a
continuum of care
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Department of Emergency Medicine
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Department of Emergency Medicine
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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
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A mature trauma system seeks to minimize
quality of care variations
An effective trauma system comprises both
patient care and social components
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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)
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Department of Emergency Medicine
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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.
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SYSTEM FINANCE
• Trauma care is lifesaving, yet expensive.
• The investment in systems can be costeffective in terms of long-term health care
costs and productivity.
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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
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OUTCOMES OF TRAUMA CARE
SYSTEMS
Does the establishment of trauma
systems increase trauma patients'
survival?
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• 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
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Trauma Center
Categorization
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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.
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• 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.
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• 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
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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
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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
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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
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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
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Summary
TRAUMA CARE SYSTEM PLAN
COMPONENTS
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ADMINISTRATIVE
COMPONENTS
– LEADERSHIP
– SYSTEM DEVELOPMENT
– LEGISLATION
– FINANCE
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OPERATIONAL AND CLINICAL
COMPONENTS
• PUBLIC INFORMATION AND
PREVENTION
• HUMAN RESOURCES
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OPERATIONAL AND CLINICAL
COMPONENTS cont’
• PREHOSPITAL
– COMMUNICATION
– MEDICAL DIRECTION
• Off-Line and On-Line Medical Direction
– TRIAGE
– TRANSPORT
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OPERATIONAL AND CLINICAL
COMPONENTS
• DEFINITIVE CARE
– TRAUMA CARE FACILITIES
– INTERFACILITY TRANSFER
– REHABILITATION
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OPERATIONAL AND CLINICAL
COMPONENTS cont’
• EVALUATION
– Data Collection
– Trauma System Evaluation
– Trauma Center Evaluation
– Research
• Trauma Care Research
• Research Funding
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