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Trauma Training: Where Do We Spend Money to Get Best Results Kris Arnold, MD, MPH, FACEP Asst Professor Emergency Medicine (retired) Boston University.

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Presentation on theme: "Trauma Training: Where Do We Spend Money to Get Best Results Kris Arnold, MD, MPH, FACEP Asst Professor Emergency Medicine (retired) Boston University."— Presentation transcript:

1 Trauma Training: Where Do We Spend Money to Get Best Results Kris Arnold, MD, MPH, FACEP Asst Professor Emergency Medicine (retired) Boston University School of Medicine Kris Arnold, MD, MPH, FACEP Asst Professor Emergency Medicine (retired) Boston University School of Medicine

2 Disclosures None

3 Objectives Explore the points in the chain of trauma response and care for the most cost- effective training points for improving outcomes. Explore options that have been employed in other resource-constrained developing trauma response systems.

4 Trauma Care Event Self/ Bystander Pre-hospital care (transport) Emergency Department In-hospital (acute care + rehab) Post- hospital

5 Points of Intervention to improve outcome PhaseHumanVectorEnvironment Pre-Event Driver Education Task training Vehicle design and maintenance Highway design Event ReactionVehicle safety features Road safety barriers Post-Event Medical Response Gas tank sealRoad quality for health care access Factors

6 The Best Bang for your Buck

7 Where/when is it happening Arreola-Risa C, Mock CN, Padilla D, Cavazos L, Maier RV, Jurkovich GJ. Trauma care systems in urban Latin America: the priorities should be prehospital and emergency room management. J Trauma. Sep 1995;39(3): Mortality (ISS  9) Seattle, USA (n=533) Monterey, Mexico (n=545)

8 Definitive Care Proximity Viet Duc St Paul Bach Mai Nagata T, Takamori A, Kimura Y, Kimura A, Hashizume M, Nakahara S. Trauma center accessibility for road traffic injuries in Hanoi, Vietnam. J Trauma Manag Outcomes. 2011;5:11. No Surprise Distance to VD => Mortality

9 Not Only Road Crashes Vietnamese burned while on phone at gas station Posted on October 25, 2012 Skyscraper on fire, 11 injured in Vietnam capital Posted on October 25, 2012 Cold wave unrelenting in Northern Region Posted on January 4, 2013 Hospitals in Hanoi, like the National Hospital of Pediatrics, Bach Mai and Saint Paul, are also treating a large number of people with weather related ailments.

10 Emergency Care Proximity

11 Injury Treatment Location Rural Vietnam Hang HM, Byass P. Difficulties in getting treatment for injuries in rural Vietnam. Public Health. Vol 123. England 2009:58-65 Distance from care was also positively associated with not getting care.

12 Catastrophic Costs WHO. Designing health financing systems to reduce catastrophic health expenditure. Geneva: WHO;2005 Hang HM, Byass P. Difficulties in getting treatment for injuries in rural Vietnam. Public Health. Jan 2009;123(1): Affordable health expenditure ≈ 5% total household income WHO defines catastrophic health care cost as ≥ 50% disposable income % Household Income spent on injury care

13 Who can give care? Event Self/ Bystander Self / bystander Care Pre-hospital care (transport) Emergency Department In-hospital (acute care + rehab) Post- hospital

14 Trauma Care in Hanoi Nguyen TL, Nguyen TH, Morita S, Sakamoto J. Injury and pre-hospital trauma care in Hanoi, Vietnam. Injury. Sep 2008;39(9): Note total %>100 since some victims received assistance from person of more than one group

15 Bystander Effect He does not really need help He will be OK I am sure someone else will take care He is probably drunk

16 Pre-hospital care (transport) Scene to Hospital Transport Emergency Department In-hospital (acute care + rehab) Post- hospital Event Self/ Bystander Transport Professional Care

17 Trauma Care in Hanoi Nguyen TL, Nguyen TH, Morita S, Sakamoto J. Injury and pre-hospital trauma care in Hanoi, Vietnam. Injury. Sep 2008;39(9):

18 Improving the Picture Mortality (%) Ali J, Adam RU, Gana TJ, Williams JI. Trauma patient outcome after the Prehospital Trauma Life Support program. J Trauma. Jun 1997;42(6): Arreola-Risa C, Mock CN, Lojero-Wheatly L, et al. Low-cost improvements in prehospital trauma care in a Latin American city. J Trauma. Jan 2000;48(1):

19 Effect of Pre-Hospital Trained Intervention Slightly greater effect in rural areas versus urban areas Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta- analysis. J Trauma Acute Care Surg. Jul 2012;73(1):

20 Truck Driver First Aid - Ghana Mock CN, Tiska M, Adu-Ampofo M, Boakye G. Improvements in prehospital trauma care in an African country with no formal emergency medical services. J Trauma. Jul 2002;53(1):90-97 Self-report No outcome data

21 In-hospital trauma care Emergency Department Post- hospital Event Self/ Bystander Pre-hospital care (transport) Emergency Department Inpatient Care

22 Meeting the need Hanoi Health Service The emergency service centre and hospitals in Hanoi can meet only 3.9% of emergency needs Hanoi Health Service. Annual Injury Prevention Report; 2006

23 Resource Matching System LevelCommuneDistrictProvince/CityCentral Unit CT/DLVN/TG Hanoi CR/VniDA/SS Hanoi KHSP Hanoi VD Hanoi Inpatient Beds Inpatients/yr ,000 % Trauma Total Trauma ,000 Doctors with Trauma Training* 0063%83%25%50%60% Nurses with Trauma Training* 20%031%24%25% 70% Son NT, Thu NH, Tu NT, Mock C. Assessment of the status of resources for essential trauma care in Hanoi and Khanh Hoa, Vietnam. Injury. Sep 2007;38(9): Relatively low frequency of cases in commune/Province/City suggests may have more need for primary trauma care training due to degradation of skills with non-use 8,106 trauma cases/yr for Hanoi population of 6 million = 22 trauma hospitalizations/day

24 So What to Do

25 Physicians & Nurses Practitioner / 10,000 population World Health Organization, World Health Statistics Ministry of Health – Five Year Health Sector Development Plan Note: Vietnam MoH reports 7 doctors/10,000 projected for 2010

26 Health Resources Per 10,000 population

27 Health Care Education Cost Thai Binh, Bach-Thai, Hai-Phong ( ) Total cost/medical student – 9,527 USD Physician training ≈ 14 X Nursing training First aid ?? Bicknell WJ, Beggs AC, Tham PV. Determining the full costs of medical education in Thai Binh, Vietnam: a generalizable model. Health Policy Plan. Dec 2001;16(4):

28 Relative Training Cost *Bicknell WJ, Beggs AC, Tham PV. Determining the full costs of medical education in Thai Binh, Vietnam: a generalizable model. Health Policy Plan. Dec 2001;16(4): **Relative pricing based on average of several US EMT tuition rates ***Based on relative cost of American Red Cross Advanced First Aid course to cost of 4 years medical school in US

29 The Human Factor District medical clinics not patronized by local residents “…shortage of good doctors and inadequate facilities” January 11, December 18, 2012 Director of the MoH’s Science and Training Department Nguyen Cong Khan said that even if the number of students who graduated from medical schools by 2020 doubled, they would still fail to meet the demands of the healthcare sector. However, at present the rate in the Cuu Long (Mekong) Delta is 5.27/10,000 and in some provinces it is even lower, such as SocTrangProvince at 3.78/10,000 and HauGiangProvince with 4.05/10,000.

30 Resource Upgrade System LevelCommuneDistrictProvince/CityCentral Unit CT/DLVN/TGCR/VniDA/SSKHSPVD Doctors with Trauma Training* 0063%83%25%50%60% Nurses with Trauma Training* 20%031%24%25% 70% AmbulancesPvt 1DH Pvt 555 Son NT, Thu NH, Tu NT, Mock C. Assessment of the status of resources for essential trauma care in Hanoi and Khanh Hoa, Vietnam. Injury. Sep 2007;38(9): *Trauma training at post graduate level = advanced specialization related to trauma or continuing education course on trauma care

31 Level of Pre-Hospital Intervention Mexico –Arreola-Risa results No improvement in mortality w/ ALS –Arreola-Risa C, Mock C, Herrera-Escamilla AJ, Contreras I, Vargas J. Cost- effectiveness and benefit of alternatives to improve training for prehospital trauma care in Mexico. Prehospital Disaster Med. Oct-Dec 2004;19(4): Developed countries –No advantage to ALS Worse mortality w GCS<9 –Stiell IG, Nesbitt LP, Pickett W, et al. OPALS Study Group. The OPALS major trauma study: impact of advanced life-support on survival and morbidity. CMAJ. 2008;178: Scoop ‘n Run vs Stay ‘n Play

32 Bottom Line All sectors could use more persons trained in organized emergency and trauma response –Continuing and upgrade education for people already working in health care with likelihood to care for emergencies and trauma The use of first responders with minimal training has been shown to decrease mortality –First responder training is much less costly than training professionals This all needs to be in the context of developing the protocols and infrastructure for an organized approach to emergency care – Regional EMS

33 Mandate for the Future Focus on raising quality of treatment in district hospitals across the country so as to help in reducing overloading in central hospitals. –doctors from the bigger hospitals to visit clinics in the countryside to share their skills Imbibe a sense of responsibility in medical staff –emphasised that medical ethics is connected with a sense of responsibility. Ordered the health sector to: Prime Minister Nguyen Tan Dung Hanoi January 24, 2013 online meeting to review the health sector’s mission in 2012 and plans for 2013

34 Aligning Sectors Many traffic accident victims died because of lacking first aid. Traffic policemen should be trained with first aid techniques. First aid stations should be set up along highways. International experts examine Vietnam’s traffic Posted on November 26, Mr. Luong Ngoc Khue Ministry of Health International Conference on Traffic Safety in Vietnam, November 23, 2012

35 Partners Husum – Village medical university Mock – Low tech interventions Karolinska/Bavi – Epidemiological data Japanese – Epidemiology/GIS plotting WHO Red Cross Small NGOs Universities

36 QuestionsQuestions

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