Trauma system

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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


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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

• Haddons Matrix

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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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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 Napoleons 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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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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Collaboration Between the Trauma System and the
Public Health

• Benefits to the Trauma System
• Benefits to the Public Health System

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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 cost-effective
  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 2040
  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 gt15
• 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
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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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