1. Workshop for Setting Regional and National Road Traffic Causality Reduction Targets in the ESCWA Region 16-17June, 2009 Abu Dhabi, United Arab Emirates Abu Dhabi, United Arab Emirates Junaid Abdul Razzak MD PhD FACEP Associate Professor and Chairman Department of Emergency Medicine Aga Khan University, Pakistan Emergency Trauma Care – Evidence for Impact on Survival

2. 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

3. WHY IS TRAUMA CARE IMPORTANT? Issue 1

4. Time and Trauma Deaths Primary Prevention Strategies Trauma Systems Trauma Systems & Rehabilitation

5. The Probability of Survival Minutes % Survival 0 20 40 60 80 100 306090 Survival Is Related To Severity and Duration

6. TRAUMA CARE SYSTEM Issue 2

7. 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;

8. Inclusive Trauma Care System Pre Hospital Phase Hospital and Post Hospital Phase

9. 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

10. EVIDENCE FOR EFFECTIVENESS Issue 3

11. 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

12. 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 !

13. PERCENT OF ALL SERIOUSLY INJURED (ISS > 9) WHO DIE Percent of injured patients who expire

14. If Care Was Equally Good.. Potential for saving hundreds of thousands of lives?

15. 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

16. 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

18. Sukumaran S. et al. 2005

20. Preventable Deaths Before and After San Diego Trauma System Implementation of Trauma System 1984 2009

21. Crash Mortality Rate Ratio Pre/post Trauma System Implementation.5.6.7.8.911.11.21.31.41.51.6 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 ratioNathens et al After adjusting for change in traffic safety laws, mortality was reduced by 8% across 21 states

22. Mortality Rate Ratio As A Function Of Time From First Trauma Center Designation Years since trauma center designation 012345678910111213141516.8.85.9.95 1 1.05 Mortality rate ratio Nathens et al Benefits of regionalization were not seen until 10-15 years after trauma center designation

24. 25% Lower in Trauma Centers! Risk of Dying: 25% Lower in Trauma Centers! 0 5 10 15 In Hospital 30 days 90 days365 days TCs NTCs NEJM 2006;354:366-78 Overall risk of death is 25% lower in trauma centers compared to non trauma centers

25. 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

26. 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

27. WHAT DOES IT ALL MEAN? Issue 4

28. Trauma Systems NOT JUST Trauma Centers Across the continuum of care Right patient – Right hospital – Right time Pre-hospital Triage Coordination (Security) Communication Transportation Rehab Conclusion I

29. CONCLUSION - 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

30. 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

31. junaid.razzak@aku.edu Thank You