2. Trauma and emergency research center 2 Trauma system Farzad Panahi MD Associate Professor of General Surgery Trauma & Emergency Research Center

3. Trauma and emergency research center 3 Definition of trauma Trauma is tissue damage caused by the transfer of energy to the body above or below the tolerance of human tissue

4. Trauma and emergency research center 4 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

5. Trauma and emergency research center 5 The Injury Pyramid EPISODES OF INJURIES REPORTED EMERGENCY DEPARTMENT VISTS 40% HOSPITAL DISCHARGES DEATHS

6. Trauma and emergency research center 6 Cost of Injuries –Direct Costs –Indirect Costs

7. Trauma and emergency research center 7 Myth: Injuries are Accidents Injuries are no accident

8. Trauma and emergency research center 8 Main concept Trauma is a disease that can be prevented or its negative impacts decreased, or both, by primary, secondary, or tertiary prevention efforts.

9. Trauma and emergency research center 9 The Injury Triangle ENVIRONMENT AGENT HOST VECTOR

10. Trauma and emergency research center 10 Concepts of Injury Control Haddon’s Matrix

11. Trauma and emergency research center 11 THE THREE PHASES OF INJURY PREVENTION PRIMARY PREVENTION: PRE-INJURY SECONDARY PREVENTION: AT THE TIME OF INJURY TERTIARY PREVENTION: POST-INJURY

12. Department of Emergency Medicine 12

13. 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.

14. Department of Emergency Medicine 14

15. Trauma and emergency research center 15 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.

16. Trauma and emergency research center 16 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.

17. Trauma and emergency research center 17 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.

18. Trauma and emergency research center 18 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

19. Trauma and emergency research center 19 Trauma Care The system encompasses a continuum of care

20. Department of Emergency Medicine 20

21. Department of Emergency Medicine 21

22. Trauma and emergency research center 22 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

23. Trauma and emergency research center 23 A mature trauma system seeks to minimize quality of care variations An effective trauma system comprises both patient care and social components

24. Trauma and emergency research center 24 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)

25. Trauma and emergency research center 25 Collaboration Between the Trauma System and the Public Health Benefits to the Trauma System Benefits to the Public Health System

26. Department of Emergency Medicine 26

27. Department of Emergency Medicine 27

28. Trauma and emergency research center 28 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.

29. Trauma and emergency research center 29 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.

30. Trauma and emergency research center 30 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

31. Department of Emergency Medicine 31

32. Trauma and emergency research center 32 OUTCOMES OF TRAUMA CARE SYSTEMS Does the establishment of trauma systems increase trauma patients' survival?

33. Trauma and emergency research center 33 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

34. Trauma and emergency research center 34 Trauma Center Categorization

35. Trauma and emergency research center 35 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.

36. Trauma and emergency research center 36 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.

37. Trauma and emergency research center 37 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

38. Trauma and emergency research center 38 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

39. Trauma and emergency research center 39 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

40. Trauma and emergency research center 40 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

41. Trauma and emergency research center 41 Paradigm Shift in Trauma Care Old ThinkingNew 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

42. Trauma and emergency research center 42 Summary TRAUMA CARE SYSTEM PLAN COMPONENTS

43. Trauma and emergency research center 43 ADMINISTRATIVE COMPONENTS –LEADERSHIP –SYSTEM DEVELOPMENT –LEGISLATION –FINANCE

44. Trauma and emergency research center 44 OPERATIONAL AND CLINICAL COMPONENTS PUBLIC INFORMATION AND PREVENTION HUMAN RESOURCES

45. Trauma and emergency research center 45 OPERATIONAL AND CLINICAL COMPONENTS cont’ PREHOSPITAL –COMMUNICATION –MEDICAL DIRECTION Off-Line and On-Line Medical Direction –TRIAGE –TRANSPORT

46. Trauma and emergency research center 46 OPERATIONAL AND CLINICAL COMPONENTS DEFINITIVE CARE –TRAUMA CARE FACILITIES –INTERFACILITY TRANSFER –REHABILITATION

47. Trauma and emergency research center 47 OPERATIONAL AND CLINICAL COMPONENTS cont’ EVALUATION –Data Collection –Trauma System Evaluation –Trauma Center Evaluation –Research Trauma Care Research Research Funding

48. Trauma and emergency research center 48