1. Chamaiparn Santikarn, MD., MPH.1Ministry of Public Health, Thailand From Provincial to National: The Development of Thailand Injury Surveillance Chamaiparn Santikarn, MD., MPH. Non-communicable Diseases Bureau, Ministry of Public Health Siriwan Santijiarakul, MSc. Epidemiology Bureau, Ministry of Public Health, Thailand

2. Chamaiparn Santikarn, MD., MPH.2Ministry of Public Health, Thailand Introduction u 1995, Thailand Provincial Injury Surveillance started in 5 large sentinel hospitals u Population under surveillance - all injury cases presenting at the emergency rooms (occurred within 7 days)

3. Chamaiparn Santikarn, MD., MPH.3Ministry of Public Health, Thailand Introduction u System objectives: Establish a database for assessing acute care and referral services; and facilitate injury prevention at provincial and national levels

4. Data flow and responsible unit E.R. Nurse Medical Record Department Medical Statistics Technicians Diskette to Epidemiology Division National action Report distributed within hospital and province Local action 4-6 mnth. 6 mnth.

5. Chamaiparn Santikarn, MD., MPH.5Ministry of Public Health, Thailand Introduction u Emphasized on local utilization for action than centralizing the data u Local information users - physicians, nurses and policymakers u PC software specifically developed for local processing

6. Chamaiparn Santikarn, MD., MPH.6Ministry of Public Health, Thailand Introduction u Menu of 35 ready-made tabulations u TRISS methodology was used to estimate survival probability u Screening tool to identify trauma cases with unexpected outcome for trauma audit u Quality of acute care services monitored

7. Chamaiparn Santikarn, MD., MPH.7Ministry of Public Health, Thailand Introduction u System expanded to 22 large hospitals u In 2001, national coordinating unit proposed reduced reporting criteria, included only severe injuries (deaths, observed and /or admitted)

8. Chamaiparn Santikarn, MD., MPH.8Ministry of Public Health, Thailand Objectives Dr. Chamaiparn Santikarn u Gain better representativeness of important injury events in each province u Better data quality u Decrease resource need 24 พฤษภาคม 2558 24 พฤษภาคม 2558 24 พฤษภาคม 2558

9. Chamaiparn Santikarn, MD., MPH.9Ministry of Public Health, ThailandMethods u To assure the sentinel hospitals Epidemiology Division used the available data u Identify workload decrease under the new criteria u Information changes due to the new criteria

10. Chamaiparn Santikarn, MD., MPH.10Ministry of Public Health, Thailand 15 study sites 7 Other sites A.D. 2001 22 reporting sentinel sites

11. Chamaiparn Santikarn, MD., MPH.11Ministry of Public Health, Thailand Methods u In December 2000 u Workshop for Establishing the National Injury Surveillance u Analysis results presented

12. Chamaiparn Santikarn, MD., MPH.12Ministry of Public Health, Thailand Results With the new reporting criteria u The number of records to be reported decreased from 197,140 to 63,607 u 68 % decrease u Total workload would be decreased by 58 %

13. Max. AIS 32456 1 No. of records Source : 15 sentinel hospitals, provincial injury surveillance, Thailand. Fig. 1 Distribution of maximum AIS of trauma cases previous vs.. new criteria, 15 sentinel hospitals, 1998

14. Chamaiparn Santikarn, MD., MPH.14Ministry of Public Health, Thailand No. of records Max. AIS 254613 Source : sentinel hospitals, provincial injury surveillance, Thailand 1998. Fig. 2 Distribution of maximum AIS of trauma cases previous vs.. new criteria, 13 non -Bangkok hospitals

15. Chamaiparn Santikarn, MD., MPH.15Ministry of Public Health, Thailand No. of records Max. AIS 135462 Source : sentinel hospitals in Bangkok, provincial injury surveillance, Thailand. Fig. 3 Distribution of maximum AIS of trauma cases previous vs.. new criteria, Bangkok,1998

16. Chamaiparn Santikarn, MD., MPH.16Ministry of Public Health, Thailand Results u 5 leading cause of injuries in each sentinel site u Minor change 2nd - 3rd rank u Tendency towards external causes with more severe outcome

17. Chamaiparn Santikarn, MD., MPH.17Ministry of Public Health, Thailand Five leading cause of injuries, previous criteria vs. new criteria previous criterianew criteria cases% % Transp. Acc 93,020 47.2 Transp. Acc 36,922 58.0 Acc. Inan. Frce 36,092 18.3 Acc. Falls * 7,987 12.6 Acc. Falls 25,597 13.0 Acc. Inan. Frce* 7,314 11.5 Assaults 16,106 8.2 Assaults 4,727 7.4 Total 197,140 100.0 Total 63,607 100.0 Self-harm 13,520 6.9 Self-harm 2,619 4.1 Others 12,085 6.5 Others 4,038 6.3

18. Chamaiparn Santikarn, MD., MPH.18Ministry of Public Health, Thailand Results u The experts and authorities supported the new criteria u Local concerns/worries u Data for administration within the hospital u Epidemics detection of some minor injuries but potential health service burden in the provincial level

19. Chamaiparn Santikarn, MD., MPH.19Ministry of Public Health, Thailand Results u The new criteria became minimum data collection standard for national injury surveillance u Hospitals could still use previous criteria to meet with internal need and provincial utilization

20. Chamaiparn Santikarn, MD., MPH.20Ministry of Public Health, Thailand Results u Simple computer technique needed to manage electronic file before sending in the data

21. Chamaiparn Santikarn, MD., MPH.21Ministry of Public Health, Thailand Results (under new criteria) u The system could continue in spite of severe manpower crisis in central coordinating unit (2002-2003) u Could report RTI victims risk behaviors monthly the Deputy Prime Minister to monitor the fight against RTI ( 2004 )

22. Chamaiparn Santikarn, MD., MPH.22Ministry of Public Health, Thailand u 28 sentinel hospitals in network u Other 12 provincial hospitals operate this surveillance model for local use u National project to promote child MC helmet - a response to surveillance report u 14 sentinel hospitals broaden roles to health promoting hospital for road safety 2005 A.D.

23. Chamaiparn Santikarn, MD., MPH.23Ministry of Public Health, Thailand Discussion

24. Chamaiparn Santikarn, MD., MPH.24Ministry of Public Health, Thailand Discussions Discussions u To much workload is common for agency collecting or managing surveillance data u Negative impact on data quality and timeliness u Capacity of computer hardware usually wasted in developing countries

25. Chamaiparn Santikarn, MD., MPH.25Ministry of Public Health, Thailand Discussions Discussions u Report of Surveillance Evaluation in Sentinel provinces (2001) u Administration within the hospital use only total number of the ER cases u Epidemics detection of minor injury not done, nor investigated

26. Chamaiparn Santikarn, MD., MPH.26Ministry of Public Health, Thailand Discussions Discussions u Report of Surveillance Evaluation in Sentinel provinces (2001) u Severe injury data – used for monitoring referral and intra-hospital trauma care u All hospitals evaluated – still used the previous criteria !?!

27. Chamaiparn Santikarn, MD., MPH.27Ministry of Public Health, Thailand Lesson learned  More difficult to live with less data after having it !

28. Chamaiparn Santikarn, MD., MPH.28Ministry of Public Health, Thailand Recommendations u Future establishment of national injury surveillance system in developing countries u Focus on severe injuries only u Aims for quality of acute care as well as prevention u Sentinel surveillance work ! u Sentinel hospitals are great partnership

29. Chamaiparn Santikarn, MD., MPH.29Ministry of Public Health, ThailandConclusion u This reporting criteria of Thailand National injury Surveillance suitable for developing countries u resources are scarce u acute care still needs improvement u injury prevention just begun

30. Chamaiparn Santikarn, MD., MPH.30Ministry of Public Health, Thailand Acknowledgment u International Collaborative Effort on Injury Statistics u LA Fingerhut, MA u U.S. CDC's NCHS, NIH's NICHD u 28 sentinel hospitals u Surveillance evaluating team

31. Chamaiparn Santikarn, MD., MPH.31Ministry of Public Health, Thailand Results u Investment for the first year (not including salary) u 3.8 million baht u approximately 10,000 US $ (according to the exchange rate at present )

32. Chamaiparn Santikarn, MD., MPH.32Ministry of Public Health, Thailand Results u Distribution of trauma cases by severity u maximum AIS scale in each patient u 161,916 cases - current criteria u 47,900 cases - new criteria

33. Chamaiparn Santikarn, MD., MPH.33Ministry of Public Health, Thailand current vs. new criteria, 15 sentinel hospitals, 1998 Fig. 4 Distribution of age of trauma cases <15-915-1925-2935-3945-4955-59 No. of records Age [year]

34. Chamaiparn Santikarn, MD., MPH.34Ministry of Public Health, Thailand Percentage Age [year] Fig. 5 Distribution of age of trauma cases compared between current v.s. new criteria, 15 sentinel hospitals, 1998 >1 5-9 15-19 25-29 35-39 45-49 55-59 % of decreased of new criteria cases

35. Chamaiparn Santikarn, MD., MPH.35Ministry of Public Health, Thailand Results Data quality A.D. 2001 New national report criteria u Report coverage u Observed & admitted 86% u Dead cases 77% u Completeness and reliability 89% u Timeliness in data entering within 30 days 46%