junaid abdul razzak md phd facep associate professor and chairman department of emergency medicine

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

junaid.razzak@aku.edu

Thank You