Trauma System Development

1. Trauma System Development Jim Holliman, M.D., F.A.C.E.P. President-Elect, I.F.E.M. Center for Disaster and Humanitarian Assistance Medicine Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland, U.S.A.

2. Trauma System Development Lecture Objectives • Present background epidemiologic information on the need for improved trauma care throughout the world • Point out the importance of Emergency Medicine (EM) as a component of effective trauma care systems • Present the World Health Organization (W.H.O.) recent policies and recommendations on trauma care

3. Acknowledgement • Thanks to my colleagues Dr. Bobby Kapur and Dr. Terry Mulligan from whom I utilized some of the modified slides used in this lecture

4. Why is Trauma Care Epidemiologically Important ? • A leading cause of death in all industrialized countries, particularly in young adults and children • Increasing relative incidence in almost all countries, including the “developing world”

6. W.H.O. Global Health Priorities World Health Organization : World Health Report 2006 Millennium Development Goals HIV, TB, Malaria, Maternal-Child Health Chronic Diseases Cardiovascular and neurological diseases Metabolic disorders and cancers Injuries Health Crises Epidemics, natural disasters, conflict .

7. W.H.O. Categorization of Countries by Income Health and Development High income : $9,206 or more. Upper middle income : $2,976 to $9,205 Lower middle income : $746 to $2,975* Low income : $745 or less Income categories based on World Bank estimates of gross national income (GNI) per capita in 2001. GNI per capita is calculated using the World Bank Atlas method (converting national currency to US dollars based on a three year average of exchange rates). Colin D. Mathers and Dejan Loncar. Updated projections of global mortality and burden of disease, 2002-2030:data sources, methods and results. WHO. October 2006. Geneva. *(Vietnam is in this group) .

8. General Relative Ranking of Health Problem Priorities High Income Countries Non-communicable Diseases (diseases of “affluence”) Trauma HIV ? Avian Influenza ? Low Income Countries Communicable diseases (HIV, TB, Malaria) Maternal-child Health Trauma Increasing non-communicable diseases Results in “Double Burden” , particularly in urban areas .

9. Epidemiologic Shift :How Do We Measure This ? Over the years various investigators have attempted to develop new measurements that factor in disability or quality of life along with mortality. One of the most recent -- and still controversial -- measures is the Disability-Adjusted Life Year, or DALY.

10. Epidemiologic Shift : DALYs In simple terms, a DALY strives to tally the complete burden that a particular disease exacts on society. DALYs combine losses from premature death with losses of healthy life resulting from disability. (defined as the difference between the actual age of death and life expectancy at that age in a low-mortality population)

11. Epidemiologic Shift : DALYs (continued) Key elements to consider include the age at which disease or disability occurs, how long its effects linger, and its impact on quality of life. e.g. : Losing one's eyesight at age 7 is a greater loss than losing one's eyesight at 67. an acute illness that is over quickly counts less in the DALY calculation than one that leaves lingering weakness.

12. . http://www.who.int/healthinfo/statistics/bodprojectionsannex08-15.xls

13. . http://www.who.int/healthinfo/statistics/bodprojectionsannex08-15.xls

14. Finally ! Recognition by the W.H.O. of the Importance of Promoting Better Trauma Care • Landmark document : Guidelines for Essential Trauma Care , W.H.O., 2004, 106 pages • Comprehensive and detailed practical recommendations for organizing trauma care at the national and local levels

15. What are the General Components Needed by a Trauma System ? • Designation of trauma care facilities • Prehospital care • Emergency department / trauma team care • Surgery / operating room care • Postoperative intensive care • Rehabilitation • Healthcare personnel training • Public education • Prevention programs

16. “Secondary” Components of Trauma Systems to Consider • Trauma case registries • Research • Cross international border cooperation in trauma referrals

17. Evidence of the Efficacy of Trauma Systems • Typical reported mortality for major trauma at many U.S. trauma centers (which have trauma teams) for the last several decades is 4 to 5 %, with some recent reports at 1% • By contrast, the previous reported mortalities from European countries without consistent use of trauma teams are typically 20 to 25 % (with range of 8 to 40 %) • These reports for example encompass France, Germany, and Switzerland

18. Multiple Reports Have Verified the Efficacy of Trauma Systems in Improving Mortality from Trauma • Some examples: • National level : McKenzie et al., NEJM 2006. • State / national level : Nathens et al., J.Trauma, 2000. • Province level : Cameron et al., NJA, 2008. • And cost effectiveness of trauma systems : MacKenzie et al., J. Trauma, 2010.

19. And Emergency Medicine Has Been Shown to be a Critical Component of an Effective Trauma System • Improved trauma outcomes at trauma centers with EM residencies : • Taylor et. Al., J Emer Med, 2005. • And older statewide data from Florida showing better outcomes at the Level 2 trauma centers staffed by EM residents compared to the Level 1 trauma centers where resuscitation was just by surgery residents

20. And the W.H.O. Has Finally Recognized the Importance of National EM Development ! • World Health Assembly Resolution 60.22 “Health Systems: Emergency Care Systems”, 2007. • Calls for all countries to provide effective care systems for trauma and emergency medicine • Recent Annals of Emergency Medicine article reviewing the importance of this resolution: Anderson et. al., 2012.

21. Further Documentation of the Efficacy of EM for Trauma Care • Holliman et al., IJEM, 2011; 4:44 (openly available online) • Reference list of 282 published articles showing efficacy of EM as a specialty and of EM physician training • 28 of the articles showed efficacy of EM for trauma care

22. Resources for Global Trauma System Development • W.H.O. Trauma and Emergency Care System Committee at W.H.O. headquarters in Geneva • I.F.E.M. has a formal representative to this • I.F.E.M. Specialty Implementation Committee • Focused courses such as A.T.L.S., the European Trauma Course, and my “Emergency Trauma Care” course

23. Difficulties to Overcome in Trauma System Development • Initial start-up costs • Competition between different facilities to be designated a trauma center • Trauma Centers and non-trauma designated hospitals need to collaborate and cooperate in the larger trauma care system • Ensuring adequate initial and ongoing training of trauma care personnel • Coordination with prehospital services

24. Positive Aspects of Trauma System Development Which Make the Development Work Worthwhile • Public reassurance and satisfaction with the system • Working with politicians for the initial system development thereby enabling further long term government support • And of course : improved trauma mortality and hopefully also improved morbidity

25. Trauma System Development Lecture Summary • Trauma is a major epidemiologic problem in all countries • The relative incidence of trauma is projected to increase in the “developing countries” • There is clear evidence that trauma systems produce improved mortality in trauma patients • There is clear evidence that EM is a critical component of effective trauma systems • The W.H.O. strongly supports improving trauma care as an important worldwide goal